mill iiiiiiiiiiiiiiiiiii iniiiiiiiiiiiiiiiniiMiiiiiiiiiiin iiiii iiiiiiiiiiniiiiij] 


PRESENTED   TO 


I  The  University  | 

1       BY  MRS.  WM.  B.  LUNN       | 
I  IN  MEMORY  OF  | 

I    William  B.  Lunn,  M.  D.    j 

fmiiii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii iiiiiiiiiiMiiiii I iiiiiiiiiiiiiiiiiiiiiiiiii 


RG^9/ 


W67 


Columbia  (Hnttiem'tp 
mt^eCilpofllfttigork 

COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


A     MONOGRAPH 


ON 


DISEASES  OF  THE  BREAST 


THEIR    PATHOLOGY   AND    TREATMENT 


Mitb  Special  IReference  to  Cancer 


W.    ROGER     \A^ILLIAMS,    F.R.C.S. 


Surgeon  Western  General  Dispensary,  and  Surgical  Registrar  Middlesex 

Hospital 


WITH    76    FIGURES 


NEW    YORK 

WILLIAM    WOOD    &    COMPANY 

1895 


SYNOPSIS    OF    CONTENTS. 


CHAPTER   I. 

Ontogeny  and  Phylogeny.  page 

The  Origin  of  the  Mammae  in  Mammalia  and  Pluman  Beings — Phyloge- 
netical  Sketch — Significance  of  Male  Mamm^ — The  Ontogeny  of  the 
Gland — The  Mammte  at  Birth — Infantile  Lactation — The  Changes  at 
Puberty,  Conception,  &c. — The  Ontogeny  and  Phylogeny  of  the 
Nipple — The  Glandiilce  Ladiferce  Aberrantes — The  Mammae,  very 
imperfectly  integrated  organs      ...         ...         ...         ...         ...         ...  i 

CHAPTER   H. 

Morphology,  Secretory  Anomalies,  &c. 

Post-embryonic  Variations — Lactation  and  Involution — Secretory  Anomalies 
— Agalactia,  Galactorrhoea  and  Heterochronous  Lactation  —  The 
Morphology  of  the  Gland — The  Corpus  MamincE  and  the  Peripheral 
Processes — The  Nipple  and  Areola — The  Axilla  ...         ...         ...  ii 

CHAPTER   in. 

Mammary  Variations  per  Defectum. 

Amazia — Complete  Absence  of  both  Mammae — Unilateral  Amazia— Micro- 
mazia — Frequent  Correlation  with  Defective  Development  of  the 
Pectoral  Region  and  of  the  Generative  Organs — Athelia — Involution 
Atrophy — Atrophy  from  Disuse — Altmann's  Researches — The  Effect 
of  Oophorectomy  on  the  Mamm^ — Syphilitic  Atrophy,  &c. — Treat- 
ment   29 

CHAPTER   IV. 

Polymastia,  with  Special  Reference  to  "  Mammae  Erratics," 
and  the  Development  of  Neoplasms  from  Supernumerary 
Mammary  Structures. 

Phylogenetical— The  Mammary  Arrangement  of  Man's  Early  Progenitors — 
The  Mammae  as  Segmental  Organs — MamniiB  ErraticcB :  dorsal, 
facial,  acromial,  femoral,  crural,  vulvar,  median,  and  within 
ovarian  dermoid  cysts — The  General  Patholos^y  of  Supernumerary 
Mammary  Structures  :  relative  frequency,  sex  distribution,  &c. — 
Polythelia  :  varieties,  instances  of  heredity — Pectoral  Polymastia, 
below  and  above  the  Normal  Structures — Abdominal  Mammre — 
Instances  of  eight,  six,  and  four  redundant  Mammary  Structures — 
Polymastia  in  Monkeys,  Cows,  Sheep,  and  other  Animals — Poly- 
mastia and  Twining — Heredity — Rarely  associated  with  other 
Anomalies— Differential   Diagnosis — Axillary   supernumerary   Mam- 


iv.  Synopsis  of  Cojttents. 

PAGE 
mary  Structures :  mostly  due  to  sequestration,  rarely  of  atavistic 
origin — The  Axillary  Mammary  Processes— True  Axillary  Poly- 
mastia extremely  Rare — Axillary  Galactoceles — Supernumerary  Mam- 
mary Structures  in  the  Vicinity  of  the  Axilla — Paramammary 
Neoplasms  arising  from  supernumerary  Mammary  Structures — The 
Frequency  of  such  Cases  demonstrated — Axillary  Mammary  Neo- 
plasms— Important  Bearing  on  Cohnheim's  Theory— Cases  of  Fibro- 
adenoma and  Cancer  thus  arising — Schultze's  Observations  on  the 
Development  of  the  Mammi-e  in  Pigs,  Rats,  and  other  Multi-mastic 
Animals— The  Mammary  Ridges,  &c 43 

CHAPTER  V. 

Hypertrophy. 

Diffuse  and  Circumscribed  Forms — Infantile  Hypertrophy  :  usually  asso- 
ciated with  precocious  Sexual  Development — Diffuse  Hypertrophy 
of  Adults :  illustrative  cases  of  the  types,  correlated  with  puberty, 
pregnancy,  &c. -Pathology,  Etiology,  Progress  and  Treatment — 
Partial  Hypertrophy  —  Gynecomastia  (a)  with  healthy  sexual 
organs  ;  (b)  with  impaired  development,  disease  or  injury  of  the 
testes — In  Male  Animals — The  Effects  of  Castration  "...         82 

CHAPTER   VI. 

Histology  and  Neoplastic  Pathogeny. 

Histology  of  the  Mamma — Histological  Metamorphoses  of  Lactation — Neo- 
plastic Processes     ...         ...         ...         ...         ...         ...         ...         ...  113 

CHAPTER   VII. 

The  Varieties  of  Mammary  Neoplasms  and  their  Relative 
Frequency. 

Analysis  of  13,824  Primary  Neoplasms,  showing  their  chief  Seats  in  both 
Sexes — The  great  Frequency  with  which  in  P'emales  the  Reproduc- 
tive Organs  are  attacked — The  Majority  of  Mammary  Neoplasms 
arise  in  the  Seats  of  greatest  Post-embryonic  Developmental  Activity, 
where  Cells  capable  of  Growth  and  Development  most  abound — The 
Relative  Frequency  of  the  Different  Varieties  of  Mammary  Neo- 
plasms :  analysis  of  2,432  consecutive  cases — Table  showing  the 
relative  Frequency  of  Neoplasms  in  general,  and  of  Female  Breast 
Neoplasms — The  Liability  of  the  Breast  to  Cancer  much  above  the 
average  for  the  body  in  general — The  great  Frequency  of  ^L^mmary 
Cancer  ;  at  least  10,000  women  now  suffering  from  it  in  England 
and  Wales— The  Influence  of  Sex  in  the  Liability  to  Neoplasms  ;  99 
per  cent,  of  all  mammary  neoplasms  occur  in  females — Function- 
less,  obsolete  .Structures,  like  the  Male  Mammne,  very  rarely  take  on 
Neoplastic  Action  ...         ...         ...         127 

CHAPTER  VIII. 

The  Pathogenesis  ok  Cancer  and  other  Neoplasms,  with  Special 
Reference  to  the  Microbe  Theory. 

Historical  Review — Galen,  Boerhaave,  Hunter,  Broussais,  Miiller,  Virchow, 
and  Cohnheim— The  Author's  Views — The  Cell  Theory  and  the 
Microbe  Theory — The  Microbe  Theory,  and  the  Broussaisian  Doc- 
trine of  Irritation  and  Chronic  Inflammation — Volkmann's  Data 
controverted  —  Critical  Examination  of  the  Microbe  Theory  — 
ii  priori  Reasons  for  regarding  the  Microbe  Theory  as  Improbable 


Synopsis  of  Contents.  v. 

PAGE 

— The  Argument  a  posteriori — The  Search  for  a  Specific  Cancer 
Microbe — Negative  Results ;  Psorospermosis  and  Cancer ;  Inocula- 
tion Experiments ;  the  Question  of  Infection  and  Epidemiology ; 
Auto-inoculability  ;  Traumatic  Dissemination;  Conclusion    ...  ...  132 

CHAPTER  IX. 

The  Morphology  of  Mammary  Cancer. 

Definition  of  the  Term  "Cancer" — Influence  of  Locality — Two  Varieties 
of  Mammary  Cancer  :  the  tubular  and  acinous — The  Term  "En- 
cephaloid  "  discarded — Clinical  Sketch  of  Acinous  Cancer — Its 
General  Morphology — The  Primary  Neoplasm — Histology — Karyo- 
kinesis  and  other  Nuclear  Phenomena — Pseudo-parasitic  Endocytes 
— The  Non-Specific  Pathogenic  Microbes  of  Cancer — Leucocytes — 
The  Stroma — Ossifying,  Chondrifying,  and  Calcifying  Varieties — The 
Blood  Vessels  and  Lymphatics  of  Cancer—  The  Absence  of  Nerves — 
Chemical  Analysis — The  Concomitant  Hyperplasia  and  its  Signifi- 
cance— The  Nitric  Acid  Method  of  Examination — -Local  Dissemina- 
tion— The  Lymphatics  of  the  Breast— Lymph  gland  Dissemination — 
General  Dissemination — Cachexia — ^Recurrence — Inflammation,  Gan- 
grene, Ulceration,  Degenerative  Metamorphoses,  the  Question  of 
Spontaneous  Cure,  &c.      ...         ...         ...         ...         ...         ...         ...  151 

CHAPTER  X. 

The  General  Pathology  of  Mammary  Cancer. 

The  Influence  of  Sex — Age — Complexion,  Race,  Geographical  Distribution 
and  Topography — Family  History  :  (a)  heredity,  {b)  correlated  here- 
ditary proclivities — The  Prevalence  of  Cancer  and  its  Increase — The 
General  Health  of  Cancer  Patients — Traumata,  Chronic  Irritation, 
and  Cancer — Multiple  Primary  Cancer  and  the  Association  of  Cancer 
with  other  Neoplasms — The  Question  of  the  Origin  of  Malignant 
from  non-Malignant  Neoplasms...         ...         ...         ...         ...         ...  233 

CHAPTER  XI. 

The  Varieties  of  Acinous  Cancer. 

The  Acute,  Chronic,    and  Melanotic  Types— ^;?   ctiirasse — Atrophic   and 

Colloid  Varieties — Carcinoma  Myxomatodes     ...         ...         ...  ...  318 

CHAPTER  XII. 

The  Clinical  Features  of  Mammary  Cancer. 

Symptomatology :  pain,  retraction  of  the  nipple,  dimpling  of  the  skin, 
discharge  from  the  nipple  —  Differential  Diagnosis  :  indtiratio 
benigna,  chronic  mastitis,  tubercle,  cold  abscess,  &c ...         ...  336 

CHAPTER  XIIL 

The  Treatment  of  Acinous  Cancer. 

Operative — Inadequate  Operations — Anatomico-pathological  Memorabilia — 
The  Essentials  of  a  thorough  Operation — The  Necessity  for  Extir- 
pating the  whole  Disease,  as  well  as  the  whole  Breast,  and  for  Clear- 
ing the  Axilla — The  Pedoralis  Major  Muscle — Description  of  the 
Author's  Operation — Antiseptic  Precautions — Skin  Grafting — The 
Mortality  and  Causes  of  Death  after  Operation — The  Question  of 
Radical  Cure — Is  Life  Prolonged  thereby? — Caustic  Treatment — 
Palliatives   ...  ...         ...         ...         ...         ...  ...  .,.         ...  94^ 


vi.  Synopsis  of  Contents. 

CHAPTER  XIV. 

The  So-called  Villous  Duct  Cancers.  page 

The  Prevalent  Confusion  as  to  the  Nature  of  these  Growths— Two  Distinct 
Kinds  of  Neoplasms  have  hitherto  been  included  under  this  Head- 
ing :  the  non-malignant  villous  papilloma  and  the  malignant 
tiihular  cancer  —Villous  Papilloma,  its  Pathology  and  Treatment  — 
Tubular  Cancer,  its  Pathology  and  Treatment — Epithelidme  tubule...  372 

CHAPTER  XV. 

Cancer  of  the  Mammary  Integument. 

Chronic  Inflammatory  Conditions  of  the  Nipple  and  Areola  preceding  Cancer 
(Paget's  Disease,  &c.) — Butlin,  Thin,  and  Duhring's  Histological 
Researches — Darier,  Wickham,  and  others  on  its  Association  with 
Psorospermia — Critical  Review  and  Conclusion — Illustrative  Cases- 


Treatment 

CHAPTER  XVI. 

Cancer  of  the  Male  Breast. 

Analytical  Summary  of  100  Cases  :  (a)  acinous,  {b)  tubular  —  Pathology  and 
Treatment — Secondary  Growths  in  the  Bones  —  Cutaneous  Epithe- 
lioma           ...         ...         ...         


CHAPTER  XVII. 

Sarcoma  of  the  Breast. 

Classification — Statistical  Summaries — Adeno-sarcoma — Pure  Sarcoma- 
The  So-called  Alveolar  Sarcoma— Myxoma — Keloid  and  its  Allies- 
Sarcoma  of  the  Male  Breast 


393 


403 


417 


CHAPTER  XVIII. 

Fibroma  and  Fibro-Adenoma. 

Pure  Fibroma — "  True  Adenoma  " — Fibro-Adenoma  ;  its  General  Morpho- 
logy, Pathology,  Diagnosis  and  Treatment ;  Instances  of  Recurrence  458 

CHAPTER   XIX. 
Lipoma,  Chondroma,  Osteoma,  Angioma,  Papilloma,  &c 483 

chaptt;r  XX. 

Cystic  Disease  and  Cysts. 

Pathogenesis — Mucoid  Cysts — Lacteal  Cysts  (galactoceles)  —  General 
Cystic  Disease  —  Lymphatic  Cysts  —  Hydatids  —  Sebaceous  and 
Dermoid  Cysts       ...         ...         ...         ...         ...         ...         ...  ..  492 

CHAPTER   XXL 

Non-malignant  Neoplasms  and  Cysts  of  the  Male  Breast. 

Fibroma  and  Fibro-Adenoma— Villous  Duct  Papilloma— Lipoma — Chon- 
droma and  Osteoma — Angioma — Cysts..,         ...         ...         509 


Synopsis  of  Contents.  vii. 


CHAPTER    XXII. 

Axillary  Tumours.  page 

Cutaneous  Neoplasms — Moles,  Nsevi,  Sebaceous  Cysts,  Molluscum,  Papil- 
loma, Melanoma,  Sarcoma  and  Epithelioma — Axillary  Mammary 
Neoplasms — Galactoceles — Angiomata — Cystic  Tumours — Lymph- 
angiomata — Lipomata — Sarcoma  and  Myxoma — Fibrous,  Carti- 
laginous and  Osseous  Tumours  —  Lympho-sarcoma  —  Lymph 
Glandular  Tumours,  &c.  ...  ..  ...  ...  ...  ...  5'^ 

CHAPTER    XXIII. 

Inflammatory  and  Suppurative  Diseases. 

Mastitis  and  Microbes — Chronic  Mastitis — Diffuse,  Periductal  and  Circum- 
scribed— Chronic  Abscess — Inflammatory  Diseases  of  the  Nipple 
and  Areola — Acute  Inflammation  and  Suppuration — Erysipelas      ...  525 

CHAPTER   XXIV. 
Tubercle,  Syphilis,  Diphtheria,  &c 554 

CHAPTER   XXV. 
Traumata,  Neuroses,  Minor  Surgery 564 


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DISEASES   OF   THE   BREAST. 


CHAPTER   I. 
The  Ontogeny  and  Phylogeny  of  the  Breast. 


S     I . Introductory. 

The  extra  uterine  continuation  of  the  nutrition  of  the  foetus 
is  effected  through  the  mammse — glandular  organs  destined  to 
secrete  milk  for  the  nourishment  of  the  young  immediately  after 
birth.  Correlated  with  these  important  organs  are  other  struc- 
tural peculiarities,  so  that,  since  the  time  of  Linnaeus,  mor- 
phologists  have  classified  all  animals  having  them  in  the  same 
order  under  the  name  of  "  mammalia."  All  such  animals  are 
viviparous  ;  their  young  are  brought  forth  naked,  without  any 
foetal  envelopes  or  stored-up  nourishment.  Hence  they  usually 
depend  for  very  existence  upon  the  ability  of  the  mother  to 
nourish  and  protect  them.  The  origin^  of  the  mammae  is  in- 
timately connected  with  this  helpless  condition  of  the  young. 

'  Mammalian  animals  are  among  the  most  highly  organised  and  latest  evolved. 
It  was  formerly  thought  that  they  came  into  existence  at  the  commencement  of  the 
tertiary  period  ;  but  it  is  now  known  that  the  leading  types,  as  at  present  existing, 
were  even  then  differentiated  ;  and  mammalian  remains  have  since  been  found 
throughout  almost  the  whole  of  the  secondary  or  mesozoic  rocks.  As  at  present 
known  mammals  are  completely  isolated  from  all  other  groups  of  animals.  Huxley 
believes  we  must  go  straight  down  to  the  amphibia  for  their  nearest  progenitors. 
According  to  Darwin,  the  descent  of  man  from  the  lowest  mammalia  is  through  the 
ancient  Monotremata  to  the  ancient  Marsupials,  and  from  these  to  the  early  pro- 

I 


2    THE  ONTOGENY  AND  PHVLOGENY  OF  THE  BREAST. 

Both  sexes  of  human  beings,  like  all  other  mammalian 
animals,  possess  mammae  ;  but  in  males  they  are  usually  small 
and  functionless.  It  is  only  in  females  that  they  develop  into 
true  milk-secreting  organs.  In  this  their  perfect  state,  the 
mammae  must  therefore  be  regarded  as  appertaining  essentially 
to  the  female  organisation.  It  is,  however,  certain  that  it  was 
not  always  so.  We  must  remember  that  the  earliest  and  most 
primitive  sexual  relation  was  hermaphroditism  ;  and  that  the 
separation  of  the  sexes,  as  they  at  present  exist,  was  only 
secondarily  effected,  by  division  of  labour,  in  the  gradual  pro- 
gress of  evolution.  Hence  in  every  male  we  still  find  rudiments 
of  female  reproductive  structures,  and  vice  versa.  But  it  is 
chiefly  in  consequence  of  sexual  selection  that  male  animals 
differ  so  widely  from  their  females,  and  that  they  tend  to  vary 
anatomically  and  pathologically  in  a  different  manner.  Thus 
were   developed  the  so-called  "  secondary  sexual   characters ; " 


genitors  of  the  placental  Mammals.  Thence  to  the  Lemuridoe  and  through  these  to 
the  Simiadae.  The  latter  then  branched  off  into  two  great  stems:  from  the  catarrhine 
or  old-world  division,  of  which — after  they  had  diverged  from  the  new-world  divi- 
sion— man,  at  a  late  period,  proceeded.  The  time  at  which  this  took  place  is  still  a 
matter  of  controversy.  It  is,  however,  much  more  remote  than  historians  and 
chronologists  have  led  us  to  believe.  The  oldest  of  such  records  prove  that  civilised 
communities  and  large  states  flourished  in  Egypt  and  some  parts  of  Asia  prior  to 
4000  B.C.  In  these  countries,  therefore,  man  must  have  had  far  higher  antiquity 
than  this.  In  Europe  his  presence  can  be  traced  in  this  way  only  to  about  2000 
to  3000  B.C.  Geologists  have,  however,  proved  his  existence  at  much  more  remote 
periods.  Geikie  says  ("Prehistoric  Europe,"  p.  2,  ^^^^i/.);  "We  know  now  that  many 
long  centuries  before  the  advent  of  the  Romans  our  islands  were  occupied  by  a  people 
whose  knives  and  swords  were  fashioned  of  bronze  ;  we  know  further  that  this  people 
was  preceded  by  a  race  or  races  ignorant  of  the  use  of  metals,  who  lived  during 
several  considerable  changes  of  climate  and  oscillations  of  the  sea  level  ;  and  we 
have  also  learned  that  at  a  still  more  remote  period  our  country  and  the  neighbour- 
ing parts  of  Europe  were  tenanted  by  tribes  of  yet  ruder  barbarians,  during  whose 
occupancy  several  extensive  geological  mutations  occurred."  On  this  subject  Prest- 
wich  remarks  ("Antiquity  of  Man,"  vol.  ii. ,  1888,  p.  534)  :  "  If  we  can  be  allowed  to 
form  a  rough  approximate  estimate  — on  data  as  yet  very  insufficient  and  subject  to 
correction — we  may  give  to  paleolithic  man  no  greater  antiquity  than  perhaps  about 
20,000  to  30,000  years  ;  while  should  he  be  restricted  to  the  so-called  post-glacial 
period,  this  antiquity  need  not  go  further  back  than  from  10,000  to  15,000  years 
before  the  time  of  neolithic  man.  The  extreme  antiquity  of  even  80,000  years  (not 
to  speak  of  150,000  to  200,000  years)  assigned  to  man,  seems  to  me  based  on  very 
inappreciable  evidence." 


ONTOGENY    OF    THE    GLAND.  3 

that  is,  those  differences  between  individuals  of  opposite  sexes 
which  appear,  not  in  the  sexual  organs  themselves,  but  in  other 
parts  of  the  body,  such  as  the  beard  of  man  and  the  breast  of 
woman.     It  is  certainly  very  remarkable  that  in  every  female 
all  the  secondary   male  characters,  and  in  every  male  all  the 
secondary  female  characters,  exist  in  a  latent  state,  ready  to  be 
evolved   under    certain    conditions.      Thus    in    men    and    male 
mammals  the  breasts  occasionally  attain  a  large  size  and  secrete 
milk.     To  account  for  the  existence  of  male  mammcX  Darwin^ 
suggests,  that  long  after  the  progenitors  of  the  whole  mamma- 
lian  order  had   ceased  to  be  androgynous,  both  sexes  yielded 
milk,  and   that  the   males  aided  the  females  in  suckling  their 
offspring ;    but  that  afterwards,  from  some  cause  (as  from  the 
production  of  a  smaller  number  of  young),  the  males    ceased 
to  give  this  aid  ;    disuse  of  the  organs  during  maturity  would 
lead  to  their  becoming  inactive,  and  this  state  would  be  trans- 
mitted to  the  m.ales  at  the  corresponding  age.     Curiously  enough, 
the  male  mammae  are  much  less  completely  aborted  than  are 
the  other  female  reproductive  structures  rudimentary  in  man. 
Having  no  use,  their  persistence  is  remarkable,  and  indicates 
high  antiquity. 


§     II. Ontogeny  of  the  Gland. 

The  human  breasts  {iiiammcE),  like  those  of  all  other  mam- 
malia, are  generally  regarded  as  greatly  enlarged  and  modified 
cutaneous  sebaceous  glands.  The  observations  of  Champneys^ 
on  the  development  of  mammary  functions  by  the  axillary 
sebaceous  glands  of  women  during  lactation  ;  as  well  as  those 
of  Duval '^  on  the  nature  of  the  secretion  of  the  acinous  elands 
of  the  areola  under  like  conditions,  show  that  the  difference 
between  sebum  and  milk  is  only  one  of  degree.     In  all  this  it 


2  "  Descent  of  Man,"  1879,  p,  163. 

3  Med.  Chir.  Trans.,  vol.  Ixix.,  1886,  p.  419. 

*  "  Du  Mamelon  et  de  son  Aureole,"  These  de  Paris,  1861,  p.  43. 


4    THE  ONTOGENY  AND  PHYLOGENY  OF  THE  BREAST. 

appears  to  me  there  is  nothing  to  countenance  the  extraordinary 
view  recently  advanced,  that  in  human  beings  highly  specialised 
organs  like  mammae  and  teeth,  which  have  taken  immense 
ages  to  attain  their  present  degrees  of  perfection,  can  be  sud- 
denly evolved,  as  "  sports  "  from  ordinary  sebaceous  glands  and 
cutaneous  epithelial  processes  respectively.  I  must  protest 
against  this  assumption,  which  is  a  contravention  of  the  funda- 
mental principle  of  heredity ;  and  as  I  have  elsewhere  shown,^ 
the  evidence  on  which  it  is  based  is  altosfether  delusive. 


Fig.  I. — Diagram   showing    Early   Stages   in   the   Development  of   the 

Breast. 

Sc.  Horny  stratum.     SAf.  Malpighian  stratum.      C.  Derma  (Wieders/ievi?). 


The  question  has  arisen  whether  the  mamma  is  the  homo- 
logue  of  a  single  sebaceous  gland  or  of  an  aggregation  of  such 
glands.  It  appears  to  me  that  here  wc  have  but  one  reliable 
guide — viz.,  the  ontogeny  of  the  organ.  Inasmuch  as  all 
observers  are  now  agreed  that  the  mamma  is  developed  from 
but  a  single  epithelial  ingrowth,  and  that  the  form  ultimately 
attained — in  which  the  gland  discharges  by  numerous  ducts  on 
the  summit  of  the  nipple — is  due  to  secondary  modification 
(kenogenesis),   I  am   decidedly   of  the   opinion  that  we  must 


'  Journal  of  Avatoviy,  vol.  xxv.,  1891,  p.  225. 


ONTOGENY    OF    THE    GLAND.  5 

regard  it  as  the  homologue  of  but  a  single  specialised  sebaceous 
gland. 

Like  all  other  glands  opening  on  the  free  surface  of  the  body, 
the  mamma  is  developed  from  the  deep  cells  of  the  epidermis 
by  a  process  of  continuously  progressive  ingrowing  gemmation 
with  differentiation  (fig.  i).  The  process  begins  at  about  the 
third  or  fourth  month  of  intra-uterine  life  by  certain  of  the 
columnar  cells  of  the  Malpighian  stratum  in  the  site  of  the 
future  organ,  proliferating  more  rapidly  than  those  adjacent 
(SM.).      A  solid,   knob-shaped    mass   of  proliferous    epithelial 


Fig.  2. —The  Mammary  Gland  of  a  Mature  Fcetus. 
{a)  Primary  ingrowth,  with  (c)  secondary  and  (i)  tertiary  offshoots  (Longer). 

cells  ingrowing  into  the  subjacent  derma  is  the  result  (primary 
epithelial  deposit).  About  this  knob  the  small,  round -celled 
embryonic  parablastic  tissue  aggregates  and  forms  a  zone  from 
which  the  nipple  is  subsequently  developed  (nipple  zone).  A 
few  weeks  later,  by  repetition  of  the  initial  process,  secondary 
buds  arise  from  the  primary  ingrowth,  and  likewise  grow  into 
the  adjacent  structures  as  solid  cellular  plugs  (secondary  epithe- 
lial deposit).  These  form  the  first  rudiments  of  the  ducts  and 
lobes,  and  it  is  only  subsequently  that  they  become  excavated. 
At  this  stage  the  nascent  gland  consists  of  a  single  branch- 
ing  system   of  proliferous  epithelial    cells    ingrowing  into  the 


6    THE  ONTOGENY  AND  PHYLOGENY  OF  THE  BREAST. 

surrounding  tissues.  In  the  derma,  beneath  the  nipple  zone, 
there  now  becomes  differentiated  a  fresh  zone  of  embryonic 
parablastic  tissue,  from  which  the  stroma  of  the  gland  is 
developed    (stroma    zone). 

In  the  next  stage  the  primary  epithelial  ingrowth  undergoes 
retrogressive  metamorphosis,  often  with  a  certain  amount  of 
cornification,  and  these  changes  eventually  lead  to  its  complete 
disappearance.  At  the  same  time  the  secondary  epithelial  in- 
growths undergo  further  development  ;  they  become  hollowed 
out  and  give  off"  numerous  club-shaped  buds  at  their  extremities 
— the  rudimentary  lobules.  In  connexion  with  these,  small 
aggregations  of  irregularly  shaped  epithelial  cells  subsequently 
appear,  which  constitute  the  matrix  for  the  development  of  the 
true  secreting  glandular  parenchyma — the  acini.  Towards  the 
end  of  intra-uterine  life  each  lobe  has  developed  a  single 
external    opening   or   duct. 

At  birth  the  organ  consists  of  from  fifteen  to  twenty  lobes, 
the  excretory  ducts  of  which  are  excavated  and  lined  with  a 
single  layer  of  small  cubical  cells,  the  rest  of  the  organ  being 
still  solid  (fig.  2).  "  In  newly-born  children,"  says  Langer,^  "  we 
rarely  find  anything  more  than  the  principal  ducts,  with  some 
indications  of  ramification  in  the  form  of  two  or  three  club- 
shaped  processes  ;  and  even  if  these  be  somewhat  more  de- 
veloped, the  terminal  vesicles  are  always  absent,  even  in  those 
cases  where  fluid  is  secreted."  This  description  has  hitherto 
been  generally  accepted,  but  it  is  now  known  to  be  true  only 
for  stillborn  children  and  for  those  who  have  died  immediately 
after  birth.  De  Sinety''  has  found  that  during  the  first  ten  days 
of  cxtra-uterinc  life  considerable  formative  changes  take  place 
in  the  gland ;  so  that  if  it  be  examined  at  the  end  of  this  period 
some  acinous  tissue  can  always  be  found,  resembling  that  of  the 
adult  female  mamma  during  lactation,  and  capable  under  certain 
conditions    of  secreting    milk.     These   changes   occur    in   both 

'  "Strieker's  Histology,"  Sydenham  Society's  TransL,  vol.  ii.,  p.  281,  1873. 
'  "  Kecherches  sur  la  Maniellc  dcs  Enfants  Nouveau-ni.'.s,"  Archives  de  Physio- 
logic, p.  293,  1875. 


ONTOGENY    OF    THE    GLAND.  7 

sexes,  and  they  are  described  by  Variot^  as  attaining  their 
maximum  between  the  eighth  and  fifteenth  days  after  birth. 
Similar  observations  have  been  made  by  Kolliker.^  Whence  it 
follows  that  the  secretion  of  milk  is  natural  in  the  newly  born 
of  both  sexes.  The  male  mammae  being  functionally  inactive 
continue  in  this  imperfectly  evolved  condition  throughout  life, 
although  they  generally  manifest  some  temporary  disturbance 
at  puberty. 

At  this  period  in  females  remarkable  structural  changes  set 
in,  but  it  is  not  until  after  conception  that  the  organ  attains  its 
full  development.  Before  puberty  the  female  breast  consists 
chiefly  of  excretory  ducts,  but  as  this  period  approaches  the 
true  secreting  structure  arises  by  the  abundant  new  formation  of 
glandular  acini.  This  wonderful  post-embryonic  transformation 
is  brought  about  by  progressive  gemmation,  with  subsequent 
differentiation,  in  the  same  way  as  the  initial  embryonic  de- 
velopment, of  which  it  is  but  a  superinduced  repetition.  Thus 
we  see  that  between  embryonic  and  post-embryonic  develop- 
mental processes  there  are  no  differences  other  than  those  of 
degree.  In  the  words  of  Paget — "  It  is  one  and  the  same 
power  which,  being  maintained  contmuously  from  the  germ  to 
the  latest  period  of  life,  determines  all  organic  formation." 
The  commencement  of  this  mammary  rejuvenescence  usually 
precedes  the  first  catamenial  period,  and  at  every  subsequent 
period  more  or  less  temporary  sympathetic  reaction  is  excited. 
But  the  most  important  changes  are  those  induced  by  the 
stimulus  of  conception,  which  converts  the  previously  function- 
less  structure  into  an  active  milk-secreting  gland.  During  this 
period  the  acini  attain  their  highest  degree  of  structural  per- 
fection; This,  however,  is  but  a  transitory  condition  which 
ceases  after  a  time,  when  the  stimulus  is  withdrawn,  and  is 
again  renewed  on  its  repetition.     During  the  intervals  between 

*  Gazette  Medicate  de  Paris,  Oct.  4,  1890.  "  Remarques  sur  la  Secretion  Lactee 
chez  les  Nouveau-nes." 

'  "  Brustdriisen  der  Neugebornen,"  Verhandl.  d.  phys.  mcd.  Ges.  %u  Wilrzburg, 
N.F.,  Bd.  xiv.,  18S0,  s.  144. 


8       THE    ONTOGENY    AND    PHYLOGENY    OF    THE    BREAST. 

these  periods  the  breast  remains  in  a  functionless  resting  state. 
These  and  many  other  similar  facts  show  that  normal  tissues 
may  remain  quiescent  for  long  periods,  and  then  suddenly  take 
on  new  phases  of  growth  and  development.  In  this  way,  then, 
the  whole  organ  is  gradually  evolved  from  the  columnar  cells 
of  the  epidermis. 

A  gland  in  its  simplest  form  is  merely  a  modification  of  a 
single  epithelial  cell  ;  and,  according  to  Goodsir,^°  each  acinus  of 
the  more  complex  glands  consists  at  first  of  but  a  single  epi- 
thelial cell.  It  seems  not  improbable  that  the  initial  germ  of 
the  mammary  gland  itself  may  be  of  this  simple  nature. 

This  account  of  its  ontogeny  is  chiefly  after  Rein,^i  Hiiss.^^ 
Kolliker^^  and  Langer.^^  Creighton^^  has  given  a  very  different 
description  of  the  process.  According  to  him  the  development 
of  the  mammary  acini  is  step  for  step  the  same  as  that  of  the  fat 
lobules,  and  the  ducts  arise  from  the  same  parablastic  matrix ; 
therefore,  the  homologue  of  the  mamma  is  not  a  cutaneous 
gland,  but  a  "  fat  body."  These  heterodox  views  have  not  been 
confirmed  by  subsequent  observers — e.g.,  Rein  and  Bowlby.^*^ 


§     III  . Ontogeny  and  Phylogeny  of  the  Nipple. 

The  nipples  {jnauunillce) — papilla-like  outgrowths  adapted 
for  being  sucked — do  not  develop  until  after  the  glandular 
elements  have  been  formed,  and  sometimes  they  never  arise. 
These  ontogenetical  phenomena  are  of  great  interest  from  the 
standpoint  of  phylogeny,  because  the  lowest  mammals — the 
monotremata — have  no  nipples.  In  them  the  milk  simply 
emerges    by    numerous   ducts    through    a   sieve-like    perforated 


"•  "  Anatomical  Memoirs,"  vol.  ii.,  p.  422,  1868. 
"  Arch.  f.  mik.  Anat.,  Bd.  xx.,  1882,  s.  431  ;  also  Bd.  xxi.,  s.  678. 
^"^  Jenaische  Zeitsckr.y  Bd.  vii.,  1873,  s.  176. 
'^  Eniioickluitgsgeschichle  des  Menschen,  1878,  s.  799. 
'*  Deiikschriften  der  Wiener  A kad.  der  Wissenschaften,  Bd.  iii. ,  Lief  2. 
^^  Journal  of  Anatomy,  vol.  xi.,  p.  I  ;    also  "  Physiology  and   Pathology  of  the 
Breast,"  p.  83,  1878. 

'"  Brit.  Med.  journal,  1882,  vol.  ii.,  p.  1 143. 


ONTOGENY    AND    PIIYLOGENY    OF    THE    NIPPLE.  Q 

patch  of  the  abdominal  skin,  from  which  the  young  animals 
have  to  lick  it.  These  ducts  open  either  on  a  flat  surface 
{prnithorynchus)  or  into  a  pouch  of  the  integument  {echidna). 
From  this  it  may  be  inferred — inasmuch  as  the  ontogeny  of 
organs  generally  represents  and  accords  with  their  phylogeny — 
that  our  mammalian  progenitors  had  no  nipples,  though  they 
had  the  glands.     The  marsupials  differ  from  the  monotremata 


Fig.  3. — Diagram  of  the  Development  of  the  Nipple. 

A.  Indifferent  stage :  glandular  area  depressed.  B.  Elevation  of  the  glandular 
area  with  the  nipple. 

(a)  Periphery  of  glandular  area,  {b)  Glandular  area,  {gl.)  Glandular  elements 
{Gegenbauv'). 


in  possessing  nipples.  According  to  Darwin,  these  structures 
were  first  acquired  by  marsupials  after  they  had  diverged  from 
and  risen  above  the  monotremata,  and  were  by  them  transmitted 
to  the  placental  mammals.  In  human  beings  at  an  early  stage 
of  development  the  site  where  the  nipple  will  subsequently 
appear  is  marked  by  a  depression,  towards  the  bottom  of  which 
the  ducts  of  the  gland  converge  (fig.  3,  A  b).  Owing  to  arrest 
of  development  at  an  early  stage  this  rudimentary  state  ma}' 
persist  throughout  life  ;    and  such  malformations  are  met  with 


lO   THE  ONTOGENY  AND  PHYLOGENY  OF  THE  BREAST. 

both  in  the  normally  placed  and  in  the  supernumerary  nipples. 
They  remind  us  of  the  mammary  pouch  of  Echidna.  The 
further  development  of  the  nipple  is  effected  by  the  area  of 
skin,  perforated  by  the  ducts,  being  raised  up  into  the  form  of 
a  papilla,  above  the  level  of  the  rest  of  the  integument  (fig.  3,  B*^). 
When  the  whole  of  the  cutaneous  area  perforated  by  the  ducts 
of  the  nascent  gland  is  not  integrated  with  the  developing 
nipple,  then  such  of  the  ducts  as  are  left  behind,  instead  of 
opening  on  the  summit  of  the  nipple,  do  so  on  the  areola,  where 
they  are  to  be  found  chiefly  about  the  base  of  the  nipple. 
Thus  the  so-called  glands  of  Montgomery  {glandidce  lactifercB 
aberrantes)  arise.  From  the  frequency  of  these  and  other 
somewhat  similar  malformations,  we  may  conclude  that  the 
mammae,  like  the  lachrymal  and  salivary  glands,  are  normally 
very  imperfectly  integrated  organs. 

At  birth  the  nipples  are  fairly  prominent  in  both  sexes. 
Their  ducts  generally  contain  disintegrating  epithelial  cells 
which  sometimes    deliquesce  into  a  milk-like  fluid. 


1 1 


CHAPTER  II. 
Morphology,  Secretory  Anomalies,  etc. 


S     I . Post-embryonic  Variations. 

The  size  and  shape  of  the  breasts  present  many  variations, 
according  to  the  influence  of  sex,  age,  function,  idiosyncrasy  ; 
genital,  racial  and  climatic  conditions.  Some  of  the  most  im- 
portant of  these  changes  have  been  briefly  sketched  in  the 
preceding  chapter.  A  few  supplemental  remarks  are  now 
necessary. 

At  puberty  the  female  breast  attains  its  typical  form,  which 
is  due  even  more  to  overgrowth  of  its  fibro-fatty  envelope  than 
to  the  glandular  ectasia.  At  this  period,  and  at  all  subsequent 
stages  of  female  organisation,  the  correlation  between  the  mam- 
mary development  and  that  of  the  internal  sexual  organs  is  a 
marked  feature.  Hence  derangements  of  the  latter  often  de- 
termine abnormal  activity  in  the  former.  The  development  of 
the  breasts  at  puberty  is  almost  invariably  symmetrical ;  but  it 
is  occasionally  delayed  in  one  of  the  glands,  even  for  several 
years,  and  this  although  the  catamenia  have  been  normally  es- 
tablished.^ Sometimes  developmental  retardation  affects  both 
breasts.  Premature  mammary  development  is  occasionally  met 
with,  mostly  in  association  with  precocious  sexual  evolution. 

The  changes  that  take  place  in  the  breasts  during  pregnancy 
are    briefly  as  follows.     At  about    the  second  month  they  get 


'  For   cases  vide  Gaz.  des  Hopitaux,  No.  24,    18S1,   p.    1074  ;    and   Neiv    York 
Medical  Record,  Oct.  10,  1891,  p.  44S. 


12  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

tender  and  begin  to  enlarge.     As  the  process  advances  this  en- 
largement becomes  more  obvious  ;    at  the  same  time  they  get 
harder,  and  bluish  veins  become  visible  in  the  skin,  especially 
around  the  areola.     This  increase  in  size  is  almost  entirely  due 
to    physiological    overgrowth    of  the    glandular    parenchyma — 
lobes,  lobules  and  acini  ;    and   it  is  accompanied  by  absorption 
of  the  interlobular  fat,  so  that  the  fully  evolved  mamma,  like 
the  pancreas  and  other  actively  secreting  glands,  consists  almost 
entirely  of  parenchymatous  tissue,  and  this  causes  the  organs  to 
feel  nodulated.     But  the  most  characteristic  signs  of  pregnancy 
are  those  associated  with  the  nipples  and  areolae.     These  parts 
deepen    in   colour   and    become  turgid.      The   nipples   become 
covered  with  minute  branny  scales,  from  desiccation  of  escaped 
colostrum-like   fluid,   which  even  as    early  as  the  third  month 
can  generally  be  squeezed  from  them.     The  areolae  get  moist  ; 
and  a  number  of  small    tubercles  (tubercles  of  Montgomery) 
develop    in    them,    forming   a   circle    around    the    nipple.      As 
pregnancy  advances  they  become  still  more  prominent.     These 
signs  are  more  reliable  in   primipane  than   in  multiparit.     The 
first  flow  of  milk  usually  sets  in  about  the  second  or  third  day 
after  delivery,  and  it  is  generally  accompanied  with  some  con- 
stitutional disturbance.     Its  normal  duration  is  from  twelve  to 
eighteen   months,  and  while  it  lasts  the  catamcnia  are  usually 
in  abeyance.     In  those  who  do  not  suckle  it  usually  ceases  in 
from   two  to  three   weeks.     After  premature  births,  and  even 
after  abortion  at  the  second  or  third  month,  the  lacteal  secretion 
is  established,  as  in  women  who  have  gone  to  their  full  term. 
After   lactation    the  breasts    gradually  revert    to   the    state   of 
passive   maturity.     The    involution   process  is  characterised  by 
extensive  atrophy  of  the  glandular  tissue,  with  re- formation  of 
fat  in  the  stroma  ;  but  the  gland  never  quite  recovers  its  virginal 
condition.     An  excess  of  lax  fibro-fatty  tissue  remains,  and  its 
peripheral  processes  have  become  elongated  and  widely  diffused. 
The  skin  covering  the  virginal  breast  is  thin,  smooth,  supple 
and  of  great  delicacy.     After  its  distension  in  association  with 
pregnancy  or  other  causes,  it  often   becomes   marked   by  fine 


SECRETORY    ANOMALIES.  I  3 

white  striae  {linecB  atrophiccE).      Marks  of  this  kind  have  very 
exceptionally  been  met  with  in  nulliparae. 

With  the  decline  of  reproductive  activity  at  the  climacteric 
period,  retrogressive  changes  set  in  and  the  glandular  paren- 
chyma begins  to  disappear,  and  the  breasts  diminish  in  size. 
As  age  creeps  on,  these  changes  become  more  marked,  and  the 
peripheral  processes  waste  away.  At  length,  of  the  once  active 
gland  there  remains  nothing  but  the  ducts,  with  here  and  there 
a  few  isolated  acini  that  have  survived  the  general  dissolution. 
These  fragments  are  embedded  in  a  stroma  of  dense  fibrous 
tissue,  interspersed  with  fat.  Degenerative  changes  in  connec- 
tion with  them  not  unfrequently  originate  small,  multiple  cysts 
— the  so-called  involution  cysts.  The  peculiar  hardness  of 
cancer  arising  at  this  period  is  due  to  the  density  of  this  fibrous 
stroma,  in  which  the  rapidly  increasing  cellular  elements  of  the 
disease  are  confined.  In  obese  women  the  fibrous  tissue  is 
largely    replaced    by    fat. 


S     II, Secretory  Anomalies. 

In  connection  with  the  functional  activity  of  the  breast  the 
following  anomalies  may  be  met  with  : — 

(i)  Agalactia^  or  complete  failure  of  the  lacteal  secretion  is 
a  rare  phenomenon.  In  cases  of  this  kind  the  breasts  undergo 
no  change  during  pregnancy,  nor  after  accoucJienient.  There  is 
usually  no  obvious  mammary  defect,  the  subject  appearing  to 
be  in  all  respects  normal.  Several  instances  of  its  hereditary 
occurrence  have  been  recorded."  Puech"*  mentions  the  case  of  a 
woman,  the  mother  of  thirteen  children,  whose  breasts  had 
never  yielded  a  drop  of  milk,  although  they  were  of  normal 
configuration.  Her  mother  gave  birth  to  twenty-three  children, 
but  like    her    daughter,   her    breasts    never    yielded    any    milk. 


^  Capron,  "  Anomalies  de  la  secretion  mammaire,"  These  de  Paris,  1877. 
*  "  Les  Mamelles  et  leurs  Anomalies,"  Paris,  1876. 


14  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

When    this   anomaly    is    met    with,   both    breasts    are    usually 
affected,   but   sometimes    only   one. 

Various  degrees  of  defective  lacteal  secretion,  short  of 
agalactia,  are  of  common  occurrence.  Both  breasts  are  usually 
affected.  The  quantity  may  be  unduly  small,  it  may  be  of 
poor  quality,  or  it  may  cease  before  its  proper  time.  These 
conditions  are  generally  associated  with  ill-health,  in  which 
ansemia  is  a  prominent  factor.*  In  their  treatment  good 
feeding,  rest — mental  and  bodily — appropriate  tonic  medicines, 
frequent  and  regular  suction  of  the  nipples,  either  by  mouth  or 
with  a  special  apparatus,  together  with  electricity  and  massage 
applied  to  the  breasts,  ovarian  and  spinal  regions,  are  the  means 
most  to  be  relied  on.  Coffee,  jaborandi  and  tasi  have  been 
recommended  as  galactagogues. 

(2)  Galactorrhcea  is  the  term  applied  to  excessive  lacteal 
secretion.  This  excess  may  manifest  itself  in  the  great  quantity 
produced  within  a  given  time,  or  in  undue  prolongation  of  the 
lactation  period.  It  has  been  estimated  that  lactating  women 
in  the  prime  of  life  normally  yield  about  1,300  grammes  of 
milk  in  twenty-four  hours.  Puech  refers  to  a  case  of  galactor- 
rhcea in  which  the  patient  lost  a  litre  of  milk  every  six  hours, 
and  in  a  case  by  Mussy,  seven  litres  were  secreted  daily.  Ex- 
cessive hypersecretion  is  a  serious  disease,  leading  to  loss  of 
appetite,  emaciation,  anaemia,  and  hectic  symptoms.  The  lacta- 
tion period  may  be  unduly  prolonged  for  a  few  months,  or  for 
several  years — even  for  twelve  years  and  upwards.  In  this  con- 
nection one  naturally  recalls  the  persistent  lacteal  secretion  of 
cows.  A  writer  in  an  old  edition  of  the  "Encyclopaedia  Britan- 
nica  "^  expresses  himself  on  this  subject  as  follows  : — "  In  Europe 
the  constant  practice  of  milking  cows  has  enlarged  the  udder 
greatly  beyond  its  natural  size,  and  so  changed  the  secretion, 
that  the  supply  does  not  cease  when  the  calf  is  removed.  In 
Columbia,  where    circumstances   are   entirely   different,  nature 


*  Vide  also  chapter  iii. ,  §  4. 

*  Seventh  edition,  vol.  ii.,  p.  653. 


SECRETORY    ANOMALIES.  1 5 

shows  a  strong  tendency  to  assume  her  original  type ;  a  cow 
there  gives  milk  only  while  the  calf  is  with  her."  As  in  agalactia, 
both  breasts  are  usually  affected,  but  sometimes  only  one,  and 
instances  of  its  heredity  have  been  reported. 

In  the  treatment  of  galactorrhoea  suckling  should  be  aban- 
doned, and  endeavours  should  be  made  to  re-establish  the 
catamenia.  Of  local  applications  the  mixture  of  belladonna  and 
iodide  of  lead  is  the  most  likely  to  be  useful,  cocaine  and  mint 
are  also  said  to  have  antigalactogogic  effects  ;  with  these  com- 
pression may  be  combined.  Internally,  iodide  of  potassium 
with  bromide  of  potassium  are  indicated ;  and  in  the  event  of 
these  failing  antipyrin^  may  be  tried. 

(3)  HeterocJironous  Lactation. — It  has  been  proved  by  De 
Sinety  and  others,  that  the  secretion  of  a  small  quantity  of  milk 
shortly  after  birth  is  of  normal  occurrence  in  children  of  both 
sexes.  When  milk  is  secreted  at  any  other  period,  except  in 
connection  with  pregnancy,  it  is  heterochronous.  Heterochronic 
lactation  has  been  very  seldom  met  with  before  puberty ;  but 
Baudelocque  mentions  the  case  of  a  girl,  eight  years  old,  whose 
breasts  secreted  milk  after  she  had  allowed  a  child  to  suck  them 
for  some  time.  In  young  girls  at  puberty  a  i&w  drops  of  mucoid 
or  lactescent  fluid  are  often  secreted,  and  also  at  the  catamenial 
periods.  Similar  conditions  have  been  observed  in  association 
with  mammary  tumours  and  certain  chronic  diseases  of  the 
uterus  and  ovaries.  Independently  of  such  conditions,  however, 
heterochronous  lactation  has  been  observed  in  non-pregnant 
women,  and  in  those  who  have  never  experienced  sexual 
intercourse.  Cases  of  this  kind  have  been  recorded  by  Beigel, 
Capron,  Duval,  Montgomery,  Puech,  Johnston,  Engstrom*  and 
others.  There  can  be  no  doubt  but  that  mechanical  irritation  of 
the  nipples,  &c.,  is  a  powerful  excitant  of  lactation ;  and  most 
of  the  recorded  cases  are  attributable  to  this  cause.  Similar 
instances  have  been  met  with  in  various  animals.     In  some  few 

"  For  two  cases  of  Suppression  of  Lacteal  Secretion  by  Antipyrin,  vide  Arch,  de 
Toe.  et  de  Gyn.,  juin,  1892. 

*  Ann.  de  Gyn.,  t.  31,  1889,  p.  283. 


1 6  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

cases  lactation  is  said  to  have  been  established  in  women  even 
long  after  the  climacteric  (Heister,  Beigel,  &c.). 
Engstrom  reports  the  following  case  : — 

A  Jewess,  aged  36,  in  whom  the  catamenia  first  appeared  at  17,  and 
subsequently  remained  regular,  although  there  was  pain  at  each  period. 
She  had  never  been  pregnant.  After  recovery  from  the  removal  by  lapar- 
otomy of  a  large  dermoid  cyst  of  the  left  ovary  of  eight  years'  obvious 
duration,  she  experienced  a  great  desire  to  have  a  child.  A  few  months 
afterwards  the  mamms  enlarged,  and  milk  began  to  flow  freely  from  both 
breasts,  although  menstruation  continued  regularly.  She  thought  herself 
pregnant,  but  it  was  not  so.     The  discharge  continued  for  two  years. 

Instances  of  the  establishment  of  lactation  in  man  and  male 
animals  have  also  been  recorded  {q.  v.  ch.  v.,  §  6). 


&     III . The  Morphology  of  the  Gland. 

In  well-developed  females  after  puberty  but  before  preg- 
nancy, the  breasts  present  as  hemispherical  swellings  at  the 
front  of  the  upper  part  of  the  chest  on  each  side.  The  ex- 
treme limits  of  their  external  configuration  extend  in  the  ver- 
tical direction,  from  about  the  third  rib  above  to  the  seventh 
below;  and  laterally,  from  near  the  edge  of  the  sternum  to 
the  anterior  border  of  the  axilla,  but  peripheral  processes  of 
the  corpus  viavimcc  reach  beyond  these  limits.  Their  ex- 
ternal configuration  depends  mainly  upon  the  amount  of  adipose 
tissue  present ;  hence  the  largest  seldom  give  the  most  milk. 
Pressure  on  the  breast  causes  a  feeling  of  nausea,  and  when 
extreme  may  even  excite  vomiting.  Well-marked  fibrous  tra- 
becular— the  so-called  suspensory  ligaments  of  Astley  Cooper" 
— unite  the  gland  to  the  overlying  skin  (fig.  4  x)  ;  and  accord- 
ing to  Giraldes**,  through  the  superficial  fascia  it  is  connected 
with  the  clavicle. 

In  healthy  young  women  the  breasts  stand  out  from  the 
chest  wall  by  virtue  of  their  own  resiliency  ;  but  after  pregnancy 

'  "  The  Anatomy  of  the  Breast,"  p.  49. 

*  Metn.de  la  Soc.  de  Chir.  de  Paris,  1851,  t.  ii.,  p.  198. 


THE  MORPHOLOGY  OF  THE  GLAND.  1 7 

they  are  gfenerally  lax  and  pendent.  The  artists  of  ancient 
Greece  regarded  no  breasts  as  truly  beautiful  that  could  not 
be  covered  by  the  hand.  The  women  of  tropical  countries 
usually  have  much  larger  and  more  pendent  mammae  than 
their  European  sisters  ;  and  residence  in  tropical  climates  tends 
to  produce  this  condition,  even  in  the  latter.  In  certain  of  the 
lower  races, ^.^.,  negresses,  Hottentots,^  &c.,the  breasts  are  often 
very  large  and  lax,  reaching  even  as  low  as  the  groins,  so  that 
the  mother  can  suckle  her  child  when  carrying  it  on  her  back 
by  throwing  the  breast  over  her  shoulder. 

Most  authors  are  agreed  that  the  left  mamma  is  rather  larger 
and  heavier  than  the  right,  that  its  association  with  the  pelvic 
sexual  organs  is  the  more  intimate,  and  that  it  is  the  more  prone 
to  hypertrophy,  and  to  originate  cancer  and  other  neoplasms. 
This  difference  in  size  is  probably  due  to  the  fact  that  most 
mothers,  being  right-handed,  suckle  chiefly  with  the  left  breast. 
Hennig^*^  and  Puech^^  are  among  the  few  who  controvert  these 
statements.  I  can  confirm  the  last  of  them  from  my  own 
experience.  ^^ 

The  average  weight  of  the  mamma,  according  to  Hennig, 
IS  from  i6o  to  556  grammes. 

From  the  summit  of  the  breast,  near  its  centre,  projects  the 
nipple,  surrounded  by  the  areola.  In  women,  other  than  young 
virgins,  its  position  is  inconstant ;  but  in  the  latter,  as  in  men, 
it  is  usually  placed  over  the  fifth  rib,^''  at  about  three-fourths  of 
an  inch  external  to  the  junction  of  the  rib  with  its  cartilage. 


'  For  an  account  of  the  celebrated  "  Hottentot  Venus,"  with  an  excellent  coloured 
drawing,  see  Art.,  "  Femme  de  Race  Boschismanne,"  St.  Hilaire,  and  Cuvier's  Nat. 
Hist,  des  Mammifers,  t.  i.  (1824),  p.  i. 

'»  Arch.  f.  Gyn.,  Bd.  ii.  (1871),  s.  331. 

"  "Les  Mamelles  et  leurs  Anomalies,"  Paris,  1876,  p.  17. 

^"^  Vide  Middlesex  Hospital  Surgical  Reports,  1888,  p.  87,  and  1889,  p.  81. 

'^  In  nearly  all  English  text  books  the  male  nipple  is  said  to  be  placed  between 
the  fourth  and  fifth  ribs.  This  subject  has  been  very  carefully  investigated  by 
Wenzel  Grliber  (AlJm.  de  I' Acad.  imp.  de  St.  Petersboiirg,  vii.,  1866,  serie  t.  x..  No. 
.10),  with  the  following  results  : — Of  loo  individuals  the  nipple  was  found,  in  12  over 
the  fourth  rib ;  in  31  over  the  fourth  intercostal  space  ;  in  43  over  the  fifth  rib,  and  in 


15  MORPHOLOGY.    SECRETORY    ANOMALIES,    ETC. 

The  mammary  gland  proper  {corpus  mam7ncs  of  Henle)  is 
embedded  in  fibro-fatty  tissue.  Freed  from  these  surroundings 
it  is  usually  described  as  an  irregularly  circular  flattened  mass, 
thicker  at  the  centre  than  at  the  circumference  ;  but  this  descrip- 
tion is  very  inadequate,  as  I  shall  presently  have  occasion  to 
show.  Its  axillary  and  inferior  segments  are  much  more  bulky 
than  the  rest.  Connected  with  the  summit  of  its  anterior  con- 
vex surface  are  the  excretory  ducts,  one  for  each  lobe,  which 
converge  towards  the  nipple.  This  surface  is  separated  from 
the  skin  by  a  thick  fatty  layer  (fig.  4,  c.c),  except  beneath  the 


Fig.  4. — Mammary  Gland  of  a  Lactating  Woman. 
(fl)  Orifice  of  glandula  aberrans ;  {l>)  Sinus  lacteus;  {c)  Fatty  layer;  {d)  Lobule 
of  the  gland  ;  (x)  Fibrous  septum  connected  with  the  cutis  (Liischka). 

nipple  and  areola,  where  there  is  no  fat.  Posteriorly,  its  slightly 
concave  base  rests  for  the  most  part  upon  the  thin  sheath  of 
the  pcctoralis  major  muscle,  from  which  it  is  separated  only  by 
loose  areolar  tissue,  in  which  numerous  outlying  glandular  pro- 


9  over  the  fifth  space.  On  the  other  hand,  of  60  persons  examined,  Luschka  (Anatomie, 
Bd.  i.)  found  that  the  nipple  was  situated,  in  6  over  the  third  rib  ;  in  8  over  the 
fourth  rib,  in  4;  over  the  fourth  space,  and  in  2  over  the  fifth  space. 


THE  MORPHOLOGY  OF  THE  GLAND.  1 9 

cesses  may  usually  be  found.  According  to  Stiles,  about  one- 
third  of  the  whole  gland  lies  below  and  external  to  the  axillary 
border  of  the  pectoralis  major.  Behind  the  gland  the  fatty 
envelope  is  scanty  or  imperfect,  and  the  glandular  lobules  come 
into  close  relationship  with  the  muscle  (Heidenhain).  It  is  im- 
portant to  remember  this  when  removing  malignant  tumours  of 
the  breast.    Sometimes  a  serous  bursa  is  met  with  here. 

Very  misleading  are  the  accounts  of  the  gland  that  describe 
it  simply  as  a  flattened  circular  mass.  The  truth  is,  as  Hennig^'^ 
has  so  well  shown,  the  fully  developed  female  mamma  has 
normally  a  tricuspid  form,  two  of  the  cusps  project  towards  the 
axilla — an  upper  and  a  lower  one — and  the  other  towards  the 
sternum.  The  upper  of  these  two  axillary  mammary  extensions 
is  frequently  prolonged  round  the  border  of  the  pectoralis  major 
muscle  right  into  the  axilla  ;  and  the  same  occasionally  happens 
with  the  lower  one.  The  sternal  process  sometimes  reaches  as 
far  as  the  edge  of  the  sternum,  which  it  occasionally  overlaps. 
In  the  ordinary  operation  of  amputation  of  the  breast  these 
processes  are  almost  invariably  cut  off  and  left  behind.  Though 
commonest  in  the  axillary  and  sternal  regions,  similar  smaller 
processes  spring  from  other  parts  of  the  surface  of  the  gland, 
and  radiate  in  the  paramammary  fatty  tissue.  On  this  subject, 
Astley  Cooper^^  remarks :  "  The  margins  of  the  breast  do  not  form 
a  regular  disc,  but  the  secreting  structure  often  projects  into  the 
surrounding  fibrous  and  adipose  tissues  so  as  to  produce  radii 
from  the  nipple  of  very  unequal  lengths,  hence,  a  circular  sweep 
of  the  knife  cuts  off  many  of  its  projections,  spoils  the  breast 
for  dissection,  and,  in  surgical  operations,  leaves  much  of  the 
disease  unremoved."  Stiles^''  describes  glandular  processes  of 
this  kind  springing  from  the  anterior  surface  of  the  gland,  as 
being  contained  within  the  so-called  ligaments  of  Cooper,  which 
bring   them    into  close    proximity  with  the    corium.     Whence 

'*  "  Ein  Beitrag   zur  Morph.  des    weib.   Milch-driise,"  Arch.  f.    Gyn.,  Bd.  ii., 
1871,  s.  331. 

'■'  "  The  Anatomy  of  the  Breast,"  1840,  p.  13. 

'"  "  Svugical  Anatomy  of  the  Breast,"  Edin.  Med.  Journ.,  June,  1892,  p.  1105. 


20  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

it  follows  that  to  completely  extirpate  a  cancerous  gland,  the 
over-lying  skin  must  be  freely  sacrificed.  These  peripheral  pro- 
cesses are  longer  and  more  attenuated  in  multiparous  than  in 
nulliparous  glands.  From  all  of  this,  it  will  be  gathered  that  the 
female  mamma  is  naturally — like  the  salivary  and  lachrymal 
glands — a  very  imperfectly  integrated  organ,  for  its  constituent 
lobules,  instead  of  being  compacted  together  in  a  small  space, 
are  generally  widely  diffused,  and  some  of  them  are  completely 
sequestrated.  From  these  isolated  supernumerary  mammary 
structures,  as  I  shall  elsewhere  show,  neoplasms  frequently 
arise. 


Fig.  5. — Injected  lobule  of  the  mammary  gland  in  lactation,   x    70  (Lauder). 

The  mamma  is  a  gland  of  the  compound  racemose  order, 
and,  like  all  such,  it  is  composed  of  excretory  duct  /ulfes,  and  of 
secreting  acini  (fig.  5).  The  secreting  part  is  made  up  of  from 
fifteen  to  twenty  distinct  lobes,  each  of  which  consists  of 
numerous  lobules,  of  which  the  acini  or  dilated  terminations  of 
the  ducts  are  the  proximate  constituents.  Each  lobe  has  its 
own  excretory  {galactophorous)  duct,  which  opens  separately  on 


THE  MORPHOLOGY  OF  THE  GLAND. 


21 


the  summit  of  the  nipple  ;  and,  as  a  rule,  there  is  no  communi- 
cation between  adjacent  ducts.  As  these  converge  towards  the 
base  of  the  nipple,  where  they  lie  beneath  the  areola,  each 
duct  presents  a  fusiform  dilatation  {sinus  lactetis,  fig.  4),  which 
acts  as  a  reservoir  for  the  milk.  In  many  animals  {e.g.,  cow, 
mare,  ewe,  goat,  &c.)  these  sinuses  attain  great  size.  In  the 
cow  they  are  often  capable  of  retaining  more  than  a  quart  of 
milk,     Velpeau    has    met    with    instances    in    which   the    walls 


Fig.  6. — Section  of  normal  mammary  gland,  showing  a  lobule  and  its  duct,  and 
the  abundance  of  the  fibrous  stroma  [Nunii). 

of  the  mammary  ducts  were  calcified.  In  their  course 
through  the  nipple  the  ducts  maintain  a  uniform  calibre,  but 
their  external  orifices  are  markedly  contracted.  As  seen  in 
transverse  sections,  they  present  a  corrugated  appearance,  owing 
to  their  wall  falling  into  numerous  folds  when  not  distended. 
According  to  Sappey,  each  duct  has  a  well-developed  coat  of 
longitudinal  organic  muscle,  in  addition  to  a  connective  tissue 
sheath,  rich  in  elastic  fibres.     Outside  the  latter  the  ducts  are 


2  2  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

surrounded  by  numerous  irregular  bands  of  organic  muscles, 
most  of  which  are  horizontal.  These  increase  in  size  and 
number  during  pregnancy  and  lactation.  It  is  owing  to  their 
contraction,  under  the  influence  of  slight  frictions,  voluptuous 
ideas,  &c.,  that  the  nipples  harden  and  become  more  prominent 
{thelothisnt). 

A  fibrous  membrane  envelops  each  of  the  constituent 
parts  of  the  gland,  but  there  is  no  capsule  in  the  ordinary 
sense.  These  are  invested  and  firmly  held  together  by  abun- 
dant dense  fibrous  tissue — rich  in  elastic  fibres  and  interspersed 
with  fat — which  penetrates  between  the  glandular  subdivisions 
(fig.  6).      It  is  to  the  presence  of  so  much  fibrous  tissue  that 


Fig.  7.— Section  of  the  Gland  during  Lactation. 
{a)  Lobules;    {b)  Acini;  (<)  Ducts;  (/)  Fibrous  stroma  {20  dia.).     (De  Sincly.) 


the  gland  owes  its  characteristic  hardness  and  toughness.  Cal- 
careous and  cartilaginous  nodules  are  occasionally  found  in  the 
stroma;  and  in  old  women,  very  exceptionally,  it  has  been  found 
completely  calcified,  as  in  cases  recorded  by  Bryk,'^  Berard,'" 
Bonnet,  and  Morgagni. 


"t:inc  petrificirtc  IJrustdruse,"  ^;r/z./  M«.   Chir.,   Bii.   xxv.,   i88l,  s.  808. 
Velpeau,  "  Maladi.-s  du  Sein,"  Paris,  1854,  p.  295. 


THE    NIPPLE    AND    AREOLA.  2$ 

i^      IV. The  Nipple  and  Areola. 

The  nipple  is  the  somewhat  conical,  dusky  outgrowth  that 
projects  from  the  summit  of  the  breast.  As  already  mentioned, 
it  contains  the  excretory  ducts  of  the  gland,  which  converge  to 
its  apex,  where  they  open  separately,  in  minute  depressions, 
between  the  rugae  of  the  cutis.  In  shape,  length,  size,  &c.,  the 
nipple  is  extremely  variable.  In  many  cases  it  is  so  short  as  to 
render  suckling  difficult ;  and  not  infrequently  it  is  retracted  to 
such  a  degree  as  to  incapacitate  the  mother  for  this  important 
duty. 

The  deeply-coloured  circular  area  surrounding  the  nipple  is 
the  areola.  Like  the  nipple  it  varies  much  in  size  and  in  other 
respects.  Its  usual  diameter  is  from  one  to  two  inches.  In  the 
"  Hottentot  Venus  "  the  areola;  attained  the  great  size  of  four 
inches  in  diameter. 

The  skin  of  the  nipple  and  areola  differs  strikingly,  in  several 
respects,  from  the  general  integument.  Owing  to  the  presence 
of  pigment  in  the  cells  of  the  Malpighian  layer,  it  is  of  a  darker 
colour  than  any  other  part  of  the  external  skin.  In  young 
virgins  it  is  pale  brown  or  pinkish,  but  after  pregnancy  it 
permanently  acquires  a  much  darker  shade.  Other  variations 
in  colour  occur  in  connection  with  complexion,  race,  and  sexual 
conditions.  The  skin  of  these  parts  is  extremely  thin,  and 
intimately  blended  with  the  subjacent  connective  tissue,  with- 
out the  interposition  of  the  usual  fatty  layer.  Its  rugose 
condition  is  mainly  due  to  connections  with  numerous  irregu- 
larly disposed  bands  of  organic  muscle,  which  are  really 
derived  from  the  normal  skin  muscles.  In  the  nipples  hori- 
zontal fibres  usually  predominate ;  but  sometimes  longitudinal 
fibres  are  in  excess.  According  to  Sappey  and  De  Sinety,^^ 
most  cases  of  retracted  nipples,  not  of  congenital  origin  nor 
due   to    organic    disease,  must    be    ascribed    to    overaction    of 


'"  "  Des  causes  amatomi(|ues  de  la  retiaclion  du  mamelon."'     C.  A',  de  la  Soc.  de 
Biologic,  1S76. 


24  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

the  latter.  Beneath  the  areola,  intimately  blended  with  the 
overlying  skin,  is  a  well  marked  layer  of  organic  muscle,  con- 
sisting of  irregularly  disposed  concentric  rings.  The  mammil- 
lary  and  areolar  integument  is  thickly  studded  with  papillae, 
those  of  the  nipple  being  exceedingly  large  and  numerous, 
many  of  them  being  compound.  In  connection  with  the  latter, 
Duval  and  De  Sinety  have  occasionally  found  tactile  corpuscles. 
It  is  also  very  abundantly  furnished  with  lobulated  sebaceous 
glands,  opening  by  minute  orifices  in  the  depressions  between 
the  papillai  which  they  serve  to  lubricate,  and  protect  from 
secretions  of  the  child's  mouth.  According  to  Sappey  neither 
hairs  nor  sweat  glands  are  found  in  the  skin  of  the  nipple.  In 
addition  to  the  foregoing,  the  nipple  is  well  supplied  with  con- 
nective tisssue,  blood-vessels,  lymphatics  and  nerves  ;  but  it  is 
quite  devoid  of  fat.  In  the  Hunterian  Micseun^^  are  some 
preparations  by  Astley  Cooper,  showing  calcareous  degenera- 
tion of  the  nipple  arteries. 

The  surface  of  the  areola  is  studded  with  numerous  slight 
projections  {tubercles  of  Monigoinery),  which  during  pregnancy 
and  lactation  become  very  prominent.  These  correspond  to  the 
orifices  of  subjacent  glands — of  which  there  are  several  varieties. 
Most  of  them  are  of  the  sebaceous  type,  all  grades  being 
represented  from  a  simple  follicle  to  a  multilobular  racemose 
gland.  During  lactation  they  secrete  a  milk-like  fluid.  Around 
the  periphery  of  the  areola,  there  exists  a  circle  of  these  tuber- 
cles. In  connection  with  each  of  them  is  a  minute  hair,  which 
may  be  readily  detected  on  careful  examination  with  a  magnify- 
ing glass.  These  glands  are  of  the  same  nature  as  those  found 
at  the  base  of  hairs  in  other  parts  of  the  body,  only  they  are 
somewhat  larger.  In  some  women  this  circle  of  rudimentary 
hairs  is  occasionally  well  developed. 

Sappey  describes  two  kinds  of  sweat  glands  as  occurring  in 
the  areola  ;  those  of  the  ordinary  small  cutaneous  type,  and 
others  much  larger  and  more  deeply  placed.     Like  the  other 


-•  Nos.  4822  and  3.     Path.  Series. 


THE    AXILLA.  25 

areolar  glands  these  also  hypertrophy  during  pregnancy  and 
lactation. 

Around  the  base  of  the  nipple  are  the  orifices  of  yet 
another  variety  of  gland  —  the  glandules  lactifercE  aberrantes. 
Their  number  is  variable,  but  several  always  exist.  These  really 
are  the  ducts  of  detached  lobes  of  the  mammary  gland,  which 
open  here  instead  of  on  the  summit  of  the  nipple.  Each  duct 
usually  presents  a  well  marked  sinus  lacteiis.  They  are  much 
more  deeply  situated  than  any  other  of  the  areolar  glands ;  and 
their  minute  structure  is  precisely  similar  to  that  of  the  normal 
mamma.  They  secrete  milk  under  the  same  condition  as  the 
latter.  Their  existence  has  long  been  a  subject  of  debate 
between  anatomists  ;  but  the  careful  researches  of  Sappey, 
Duval,  De  Sinety^^  and  others,  have  now  placed  the  matter 
beyond  dispute.  According  to  Sappey  the  main  mammary 
ducts  occasionally  give  off  a  branch  that  opens  directly  on 
the  areola. 

§    V. The  Axilla. 

The  mammary  gland,  its  blood-vessel,  lymphatics,  and 
nerves  have  such  intimate  relations  with  the  axilla,  that  I  must 
here  introduce  a  few  remarks  about  its  anatomy. 

The  skin  of  this  part  of  the  body  is  pigmented  and  firmly 
connected  with  the  subjacent  fascia.  It  contains  numerous  large 
sebaceous  glands,  long  hairs  and  dense  lymphatic  net  works. 
Under  the  influence  of  pregnancy  these  glands  often  enlarge  and 
secrete  a  milk-like  fluid,  thus  originating  the  "  axillary  lumps  " 
of  Champneys.  Beneath  the  skin,  over  the  top  of  the  axilla, 
where  the  adhesions  with  the  fascia  lata  are  especially  well 
marked,  a  brownish,  lobulated,  roundish  pldque — about  the  size 
of  a  florin — may  usually  be  seen.  This  structure  was  first  in- 
vestigated by  Sappey,*^  who  found  it  comprised  numerous 
large,  tubular,  coiled  glands,  like  sweat  glands,  but  penetrating 


-'  Bull,  de  la  Soc.  Anal.,  t.   Hi.,  p.  460.     He  has  found  that  about  four  of  these 
glands  exist  in  fourteen  out  of  every  fifteen  women. 

'-"'   Trailc  d'Aualo/nte  Descriplive,  t.   iii.   (187T),  p.  546. 


26  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

more  deeply.  Sometimes  these  glands  are  irregularly  scattered 
about  the  axilla,  instead  of  being  aggregated  into  a  distinct 
layer,  and  they  are  occasionally  scanty  or  altogether  wanting. 
Similar  structures  have  been  found  in  connection  with  the  skin 
of  various  mammals  and  batrachians.  It  has  been  suggested 
that  the  axillary  odour,  which  characterises  certain  individuals 
of  both  sexes,  is  associated  with  their  marked  development. 
Creighton^  has  seen  neoplasms  originate  from  them  in  dogs  ;  and 
he  thinks  that  in  human  beings  certain  axillary  tumours  may 
spring  from  this  source.  Ordinary  sweat  glands  also  abound  in 
the  axillary  skin.  Between  these  various  glandular  structures 
and  the  overlying  skin,  bands  of  unstriped  muscle  fibres  are  dis- 
tributed. 

The  outer  wall  of  the  axilla  is  a  region  that  the  operating 
surgeon  will  avoid  as  much  as  possible,  because  here  lie  the 
axillary  vessels  and  nerves,  the  artery  being  between  the  nerve 
cords,  with  the  vein  on  its  inner  side.  The  general  tend  of  their 
branches  is  inwards,  towards  the  thorax,  but  the  veins  of  course 
proceed  in  the  converse  direction.  When  the  arm  is  raised 
above  the  shoulder,  the  head  of  the  humerus  projects  into  the 
axilla,  and  displaces  the  large  vessels  downwards  and  towards 
the  chest;  this  should  be  borne  in  mind  when  operating  in 
this  locality. 

The  posterior  wall  of  the  axilla  is  also  an  undesirable 
region  to  trench  upon  during  operations,  for  here  are  the  sub- 
scapular blood-vessels  and  nerves  (to  teres  major  and  latissimus 
dor  si). 

There  are  fewest  obstacles  to  surgical  proceedings  in  the 
vicinity  of  the  inner  wall  of  the  axilla.  Here  the  only  important 
structure  likely  to  be  injured  is  the  long  thoracic  nerve,  which 
proceeds  almost  vertically  downwards,  on  the  serratus  magnus 
muscle,  to  which  it  is  distributed. 

The  breasts  are  well  supplied  with  blood-vessels,  which  are, 
however,  very  variable  in  their  origin  and  course. 


-^  Med.  C/iir.  Trans,   vol.   Ixv.  (1882),   p.   53. 


THE    AXILLA.  2'] 

The  arteries  come  chiefly  from  the  axillary  and  the  internal 
mammary  (br.  of  the  subclavian) — each  of  these  giving  two  or 
three  branches. 

The  axillary  supplies  the  following : — 

(i)  The  long  thoracic,  which  arises  beneath  the  pectoralis 
minor  and  courses  along  the  lower  border  of  that  muscle  to 
the  chest,  where  it  gives  branches  to  the  external  and  inferior 
segments  of  the  breast. 

(2)  The  external  mammary,  which  arises  from  the  axillary, 
below  the  foregoing,  and  is  distributed  to  the  lower  part  of  the 
gland.  It  not  infrequently  takes  origin  from  the  long  thoracic. 
Both  of  the  foregoing  send  branches  to  the  nipple. 

(3)  The  thoracic  branch  of  the  acromio-thoracic,  which  arises 
from  the  axillary  above  the  pectoralis  minor,  also  sends  branches 
to  the  upper  part  of  the  mamma,  after  perforating  the  pectoralis 
major. 

The  internal  mammary  gives  off  direct  branches,  which 
perforate  the  second  and  third  intercostal  spaces,  and  are 
distributed  to  the  sternal  part  of  the  gland ;  and  through  its 
intercostal  branches — of  the  second,  third,  fourth  and  fifth  spaces 
— it  also  sends  numerous  twigs  indirectly  to  this  part  of  the 
breast.  The  aortic  intercostals  also  send  numerous  small 
branches  to  its  deep  surface.  Through  its  anastomosis  with 
the  internal  mammary  artery,  the  deep  epigastric  (br.  of  ext. 
iliac)  also  contributes  to  the  mammary  circulation. 

With  regard  to  the  veins,  the  deep  ones  for  the  most  part 
accompany  the  arteries ;  but  the  superficial  ones,  which  are 
numerous,  take  different  courses.  Some  of  them  join  to  form 
a  venous  circle  round  the  areola — the  circidus  venosus  areolcB  of 
Haller — others  enter  the  cephalic ;  and  many  pass  over  the 
clavicle,  to  unite  with  the  external  jugular  and  subclavian  veins. 

The  nerves  of  the  breast  and  the  skin  covering  it,  come  from 
the  second,  third,  fourth,  fifth  and  sixth  intercostals ;  from  the 
thoracic  branches  of  the  brachial  plexus ;  and  from  descendino- 
branches  of  the  cervical  plexus.  Communications  take  place 
between    the  intercostal  branches  and  filaments  supplying  the 


2  8  MORPHOLOGY,    SECRETORY    ANOMALIES,    ETC. 

skin  of  axilla,  inner  side  of  arm,  shoulder  and  scapula.  These 
nervous  intercommunications  explain  the  wide-spread  pain 
sometimes  experienced  in  certain  mammary  affections. 
Branches  from  the  sympathetic  accompany  the  mammary 
blood-vessels. 

The  anatomy  of  the  mammary  and  axillary  lytnphatic  system 
has  such  important  practical  bearings  in  connection  with  cancer, 
that  it  will  be  more  convenient  to  describe  it  when  treating 
of  this  subject,  rather  than  here  (^.  v.  ch.  ix.,  §  5). 


29 


CHAPTER    III. 

Mammary  Variations  Per  Defectum. 


§  I- 


-Amazia. 


The  development  of  the  breast  may  fail  at  any  stage  of  its 
evolution —  from  early  embryonic  life  up  to  the  climacteric 
period.  When  the  morbid  process  sets  in  before  the  second  or 
third  month  of  intra-uterine  life,  there  results  complete  suppres- 
sion of  the  organ — amazia. 


Fig.  8. — Complete  absence  of  both  mammae  and  nipples  (  Wylie). 

In  animals  having  normally  a  large  number  of  mammae, 
some  of  them  are  often  aborted  in  this  way,  and  the  males  of 
such  animals  often  have  fewer  than  their  females  ;  but  in 
human  beings  and  other  bimastic  animals,  amazia  is  a  very 
rare  affection — much  rarer,  for  instance,  than  polymazia.  Most 
of  the  cases  hitherto  recorded,  in  which  the  sex  has  been  well 
marked,  have  been  in  females. 

The  deformity  is  frequently,  but  by   no   means   invariably, 


30  MAMMARY    VARIATIONS    PER    DEFECTUM. 

associated  with  grave  malformations  per  defectum  of  the  ad- 
jacent chest  or  of  the  sexual  organs.  One  or  both  breasts  may 
be  affected. 

Complete  absence  of  both  mammae  is  one  of  the  very  rarest 
congenital  deformities.  Most  cases  have  been  met  with  in 
acephalous  monsters,  associated  with  deficient  development  of 
the  thorax. 

I  know  of  only  four  instances  unaccompanied  by  such 
conditions. 

Case  I.' — A  single  woman,  aged  21,  who,  when  examined  three  months 
after  giving  birth  to  a  healthy  male  child,  was  found  to  present  no  trace 
whatever  of  mammae,  areola,  or  nipples  (Fig.  8).  Not  a  drop  of  milk  had 
been  secreted,  so  that  she  was  unable  to  suckle.  Menstruation  set  in  at  15, 
and  she  had  since  been  regular.  But  for  the  mammary  deformity  she  was 
well  made,  and  her  health  had  been  good.  In  answer  to  a  letter  of  inquiry, 
Dr.  Wylie,  her  medical  attendant,  kindly  informed  me  that  there  was  no 
deficiency  of  the  pectoral  muscles  or  ribs,  and  that  the  external  genitals, 
the  teeth,  hair,  and  other  dermal  appendages,  were  well  developed. 

Case  II.^ — A  woman,  who  one  week  previously  had  been  prematurely 
delivered  of  a  living  child,  presented  no  trace  of  mammae  or  nipples  ;  but 
in  the  position  of  each  of  the  latter  was  a  pigmented  patch  of  skin,  the  size 
of  a  sixpence. 

Case  III.' — In  this  case  the  patient  was  a  boy  3^  years  old,  in  whom 
complete  absence  of  both  mammas  from  birth  was  associated  with  similar 
absence  of  hair,  and  an  atrophic  condition  of  the  whole  integument  and  its 
appendages,  except  that  of  the  external  genitals.  The  latter  were  well 
developed,  except  for  phimosis  ;  and  presented  a  remarkably  plump 
appearance,  as  compared  with  the  shrivelled  aspect  of  the  rest  of  the  body. 
The  testes  were  well  placed  and  normal.  The  boy's  mother  had  suffered 
from  alopecia  areata  from  the  age  of  16. 

Case  IV.'* — The  subject  of  this  observation  was  a  so-called  hermaphro- 
dite, aged  65,  who  had  always  passed  for  a  female.  On  examination  of  the 
body  after  death,  its  general  appearance  was  that  of  a  male,  and  there  was 
a  tremendous  beard.  Both  mammae  were  completely  absent.  Menstrua- 
tion had  never  occurred,  nor  was  there  any  history  of  sexual  desire.  Further 
examination  was  limited  to  the  genital  organs.  The  clitoris  was  very  large — 
quite  as  large  as  in  many  competent  males.  The  corpora  cavernosa  were 
large  ;  there  was  a  bulb  to  the  urethra,  a  rudimentary  prostate,  and  rudi- 


'  Wylie,  W.,  Brit.  Med.  Jour.,  1888,  vol.  ii.,  p.  235. 

^  Batchelor,  H.  T.,  Brit.  A/ed.Jour.,  1888,  vol.  ii.,  p.  876. 

'  Hutchinson,  J.,  Afed.  Chir.  Trans.,  vol.  Ixix.  (1886),  p.  473. 

'  Pilcher,  Lancet,  vol.  i.  (1838),  p.  915. 


AMAZIA.  31 

mentary  ejaculatores  seminis.  In  addition  there  was  a  rudimentary  uterus 
and  vagina  —  the  latter  ending  in  the  urethra.  Nothing  is  said  about 
ovaries  or  testes. 

Complete  absence  of  07ie  breast  is  only  a  little  less  rare  than 
that  of  both.  Several  authors  have  stated  that  the  right  breast 
is  the  one  more  frequently  affected.  I  am  unable  to  support 
this  statement ;  for,  as  will  be  seen  below,  in  most  of  the  cases 
collected  by  me  the  deformity  was  on  the  left  side.  It  is 
alleged  sometimes  to  occur  independently  of  any  other  defor- 
mity. Birkett^  cites  a  case  (Marandel's)  of  this  kind ;  but,  on 
looking  up  his  reference,^  I  found  the  record  so  meagre  and 
unsatisfactory,  that  I  was  unable  to  determine  whether  there 
was  associated  deficiency  of  the  pectoral  muscles  or  not. 

In  the  following  cases  unilateral  amazia  was  correlated  with 
malformation  of  the  adjacent  chest  wall  : — 

Case  I.^ — In  a  woman  aged  30,  who  died  of  peritonitis  eight  days  after 
her  confinement,  there  was  found  in  place  of  the  right  breast  a  shallow 
depression  ;  but  no  trace  of  the  nipple,  areola,  or  gland.  Beneath  the  skin 
there  was  nothing  but  a  thin  layer  of  adipose  tissue.  The  left  breast  was 
well  developed  and  full  of  milk.  The  anterior  parts  of  the  third  and  fourth 
ribs  were  absent,  together  with  the  corresponding  intercostal  muscles,  the 
sternal  part  of  the  pectoralis  major  muscle,  the  whole  of  the  pectoralis 
minor  and  portions  of  the  serratus  magnus.  The  gap  was  closed  in  by 
tough  aponeurosis.     The  pleura  and  lung  were  normal. 

Case  II.® — Here  the  patient  was  a  healthy-looking  girl,  5  years  old, 
whose  parents  also  were  healthy  and  free  from  any  deformity.  Of  the 
right  mamma,  nipple,  and  areola  there  was  no  trace  ;  the  skin  over  this 
region  was  like  that  of  the  rest  of  the  body.  The  pectoralis  major  and 
minor  muscles  were  deficient,  as  well  as  the  anterior  part  of  the  fourth  rib 
and  the  adjacent  intercostal  muscles.  At  this  spot,  during  respiratory 
movements,  hernial  protrusion  of  the  pleura  took  place,  the  overlying  skin 
being  in  close  contact  with  the  latter.  The  six  upper  ribs,  except  the  first, 
were  markedly  bent  and  arched  forwards  on  both  sides,  causing  consider- 
able deformity  of  the  thorax.     The  left  mamma  was  normal. 

Case  III.^ — In  this  case  complete  absence  of  the  left  breast  was  associated 
with  absence  of  the  left  upper  limb,  which  was  represented  only  by  a  small 


*  "Diseases  of  the  Breast,"  1850,  p.  23. 
^  Diet,  des  Sci.  Mid.,  t.  xxx.,  p.  378. 

'  Froriep,  Neue  Notizen,  Bd.  x.,  1839,  s.  9. 

*  Reid,  Froriep' s  Neue  Notizen^  No.  500,  Bd.  xxiii.,  1842,  s.  254. 

'  Forster,  A.,  Die  Missbld.  des  Mensch.,  1861,  s.  105,  in  atlas,  Taf.  xi.  f.  16. 


32  MAMMARY    VARIATIONS     PER    DEFECTUM. 

conical  stump  at  the  shoulder.  There  was  also  large  deficiency  of  the  thoracic 
wall  on  this  side,  through  which  the  thoracic  and  abdominal  viscera  pro- 
truded, covered  only  by  a  membranous  envelope. 

Case  IV. '" — A  girl,  aged  lo,  with  complete  absence  of  the  left  mamma, 
areola,  and  nipple.  The  sternal  part  of  the  pectoralis  major  also  wanting. 
The  other  breast  normal.  No  heredity.  The  mother  attributed  the  disease 
to  fright  during  pregnancy,  from  having  seen  a  woman's  chest  after  amputa- 
tion of  the  breast. 

Case  V.'' — In  a  healthy  married  woman,  aged  22,  shortly  after  her  first 
confinement,  complete  absence  of  the  left  breast  was  noticed  by  the  medical 
attendant.  The  nipple  was  represented  by  a  small  pimple.  The  pectoral 
muscles  of  the  affected  side  were  imperfectly  developed.  The  woman's 
mother  first  noticed  the  deformity  three  weeks  after  the  patient's  birth.  She 
attributed  it  to  having  been  frightened  when  pregnant  by  a  woman  who 
called  at  her  house  and  exposed  her  chest,  showing  marks  from  amputation 
of  her  breast  for  cancer. 

:  Case  VI.'- — A  single  woman,  aged  21,  with  complete  left  amazia.  The 
pectoralis  major  imperfect.  The  patient  otherwise  well  formed.  No 
heredity. 

Case  VI I. '^ — In  a  man  seen  by  Birkett,  left  amazia  was  associated  with 
deficiency  of  the  lower  fibres  of  the  pectoralis  major  muscle. 

Case  VIII.'^ — Young  has  reported  an  instance  of  absence  of  the  sternal 
portion  of  the  pectoralis  major  muscle  in  a  man,  whose  nipple  also  was 
stunted,  and  no  trace  of  mammary  structure  could  be  detected. 

Other  cases  have  been  recorded  by  Lousier'''  and  Schlozer.'^ 

Referring  to  the  former  of  these  cases,  St.  Hilaire'^  says  : — "  Le  Dr. 
Lousier  fait  mention  d'une  dame  qui  privee  d'une  mamelle,  transmit  a  sa 
fiUe  le  vice  de  conformation  dont  elle  etait  elle-meme  affectee."  In  accord- 
ance with  this,  almost  all  subsequent  authors  have  referred  to  the  case  as  an 
example  of  hereditary  transmission  ;  but,  according  to  Puech,'**  Lousier 
never  asserted  this.  All  he  said  was,  "  J'ai  connu  une  dame  et  une  de- 
moiselle chez  les  quelles  la  glande  mammaire  manquait  completement  d'un 
cote. 

In  the  two  following  cases  congenital  amazia  was  associated 
with  total  absence  of  the  corresponding   ovary.     Both  are  re- 


'"  King,  Med.  Times  and  Gaz.,  1858,  vol.  i.,  p.  527. 

"  Paul],  Lancet,  1862,  vol.  i.,  p.  648. 

'■-  Widmer,  Corresp.  Blatt.  f.  schw.  Aerzte,  1888,  s.  472. 

'^  Holmes'  "System  of  Surgery,"  vol.  iii.,  1883,  p.  460. 

"  Lancet,  vol.  i.,  1894,  p.  313. 

'^  '*  Dissert.  Anat.  et  Physiol,  sur  la  secretion  du  lait,"  These  de  Paris,  An.  x., 
No.  53,  p.  15. 

'"  "  Ueber  die  angebornen    Missbild.    der    gesam.    weibl.     Genitalien.     I.D., 
Erlangen,"  1842. 

"  Ilistoire  des  Anomalies,"  t.  i.,  p.  710. 
"  Les  mamelies  et  leurs  anomalies,"  p.  63. 


MICROMAZIA.  T)$ 

ported  by  Scanzoni,^^  and  I  know  of  no  others  precisely  similar, 
although,  as  I  shall  presently  mention,  there  are  on  record 
many  cases  of  micromazia  associated  with  deficient  ovarian 
development. 

The  first  patient  was  a  beggar  woman,  who  died,  aged  64,  of  tubercle. 
There  was  complete  absence  of  the  left  mamma,  nipple,  and  areola,  and  at 
the  necropsy  no  trace  could  be  found  of  the  left  ovary.  She  had  been 
subject  to  amenorrhcea  since  the  age  of  27,  but  she  had  previously  men- 
struated regularly. 

The  second  patient  was  a  girl,  aged  18,  who  died  of  typhoid  fever.  In 
this  case  right  amazia  was  associated  with  complete  absence  of  the  right 
ovary.     She  had  menstruated  regularly. 

Absence  of  the  breast  may  occasionally  be  caused  by  inflam- 
mation and  injuries  in  the  newly  born. 

Puech^"  relates  the  case  of  a  girl,  aged  17,  of  whose  left  breast  there  was 
hardly  a  trace,  although  the  right  was  well  developed.  This  resulted  from 
acute  inflammation  of  the  part  at  birth,  followed  by  suppuration  and  the 
formation  of  a  large  abscess,  which  had  to  be  incised. 

S     II.  —  Micromazia. 

When  the  defect  is  less  complete  than  in  the  above  cases,  we 
get  a  very  small  imperfectly-developed  gland,  like  the  normal 
male  breast,  or  smaller — micromazia.  This  condition,  though 
rare,  is  of  more  frequent  occurrence  than  any  of  the  foregoing. 
The  rudimentary  organs  are  useless  for  lactation.  Both 
mammae  may  be  affected,  or  only  one. 

The  deformity  occurs  independently,  or  associated  with 
malformations   of  the   adjacent   chest  or  of  the  sexual  organs. 

The  three  following  instances  of  micromazia  of  independent 
origin  are  related  by  Puech  :^^ — 

In  a  single  woman,  aged  24,  there  was  complete  absence  of  the  projection 
of  the  bosom  on  both  sides,  while  the  nipples  and  areolee  were  small  and 
stunted.  Menstruation  set  in  at  15,  but  the  catamenia  were  not  regular  until 
two  years  later.     Her  mother  and  sisters  had  well-developed  breasts. 

In  another  case  it  was  noticed  that  both  the  breasts  of  a  woman  about 

'^  Kiwisch,    Klin.    Vortrdge  iiber  spec.  Path.  u.    Therap.  d.    Kt-atik.    des   weib. 
Gesch.,  Bd.  iii.  (1855),  s.  47. 
-"  Op.  cil.,  p.  90. 
*'  Op.  ciL,  p.  89. 

3 


34  MAMMARY    VARIATIONS    PER    DEFECTUM. 

to  be  confined  were  rudimentary,  and  they  remained  so  after  delivery,  only 
a  few  drops  of  colostrum  being  secreted.  Her  mother  had  a  similar 
deformity. 

In  the  next  case  only  one  breast  was  affected.  The  patient  was  a  young 
woman  who  married  early,  and  was  the  mother  of  three  children.  At 
puberty  the  asymmetrical  condition  of  the  mammas  was  first  noticed,  for 
while  the  right  attained  its  full  size  the  left  remained  undeveloped.  After 
each  pregnancy  the  right  gave  plenty  of  milk,  but  the  left  none. 

McGillicuddy--  relates  the  case  of  a  delicate  hysterical  woman,  aged  26, 
the  condition  of  whose  mammce  resembled  that  of  a  man,  and  no  glandular 
structure  could  be  detected. 

As  examples  of  micromazia  associated  with    malformation 

of  the  adjacent  chest  wall,  I  can  cite  the  following : — 

In  a  single  woman,  aged  21,  seen  by  Engestrom,-''  all  that  existed  of  the 
left  breast  was  a  small  stunted  papilla,  and  under  it  "  un  petit  amas  de 
graisse,  mais  si  insignifiant  qu'il  ne  forme  meme  pas  une  eminence."  The 
sternal  part  of  the  \e.{\.  pectoralis  major  muscle  was  completely  absent.  She 
was  otherwise  well  developed. 

In  another  case  by  the  same  author,  the  patient  was  an  emaciated 
phthisical  woman,  aged  27,  who  had  recently  been  delivered  of  her  second 
child.  The  left  breast  was  well  formed,  and  full  of , milk,  but  the  right  was 
very  small,  although  its  nipple  and  areola  were  normal,  and  only  a  few 
drops  of  milky  fluid  could  be  expressed  from  it.  This  secretion  ceased 
shortly  afterwards.  Most  of  the  sternal  part  of  the  corresponding /i?<r/^ni://5' 
major  muscle  was  absent.  No  history  of  any  malformation  in  others  of  her 
family. 

In  a  similar  case,  seen  by  Ebstein,-'  the  right  breast  was  not  larger  than 
a  hemp-seed.  The  sternal  part  of  the  pectoralis  major,  and  the  whole  of 
ihe  pectoralis  ininor,  muscles  were  wanting. 

Griiber^''  saw  a  young  lady,  aged  18,  in  whom  nearly  all  of  the  costo- 
sternal  part  of  the  right  pectoralis  major  muscle  was  wanting,  and  whose 
right  breast  was  represented  only  by  a  malformed  nipple,  surrounded  by  a 
large  areola,  beneath  which  a  thin  glandular  plague  could  be  felt.  Men- 
struation set  in  at  15,  but  the  right  mamma  never  developed,  although  the 
left  attained  a  large  size.  She  was  otherwise  well  formed,  but  thin  and 
phthisical. 

A  less  degree  of  the  same  condition  is  shown  in  fig.  9.  The  patient  was 
a  very  anaemic  woman,  aged26,  the  mother  of  several  children.-"  The  left 
breast  was  so  ill-developed  as  to  be  less  than  half  the  size  of  the  right. 
During  lactation  it  gave  but  a  scant  supply  of  milk.  The  left  pectoral  region 
was  very  flat,  and  the  subjacent  muscles  appear  wasted. 

«  N.   Y.  Medical  Record,  Oct.  10,  1 891,  p.  448. 

-^  Ann.  de  Gyn.,  t.  xxxi.  (1889),  p.  84. 

'"  Deutsch.  Arch.  f.  klin.  Med.,  vi.,  s.  283. 

'■^  Arch.  f.  path.  Anat.,  cvi.,  1886,  s.  501. 

■■"'  McGillicuddy,  N.Y.  Medical  Record,  Oct.  10,  1891,  p   446. 


MICROMAZIA. 


35 


The  following  cases  illustrate  the  connection  between  micro- 
mazia  and  defective  development  of  the  generative  organs.  In 
nnany  of  the  individuals  thus  affected  the  secondary  sexual 
characters  are  imperfectly  evolved,  and  there  is  often  manifest 
an  approach  to  the  male  type  of  organisation. 

In  a  woman,  aged  26,  seen  by  De  Sinety,-"^  both  breasts  were  like  those 
of  a  girl  before  puberty  ;  they  had  no  areolae,  and  their  nipples  were  hardly 
perceptible.  The  uterus  and  vagina  were  of  an  equally  stunted,  infantile 
type. 


Fig.  9.  —  Defective  development  of  the  left  breast  and  pectoral  region  {McGilliciiddy). 


In  a  case  recorded  by  Greenhow-^  the  patient  was  an  unmarried  servant 
girl,  aged  22,  who  was  very  flat  in  the  mammary  regions,  and  on  careful 
manipulation  no  trace  of  either  gland  could  be  felt,  although  she  had  a  small 
stunted  nipple  and  areola  in  the  usual  position  on  each  side.  She  was  of 
spare,  girlish  aspect,  and  had  never  menstruated.  The  pelvis  and  hips  were 
small,  as  was  also  the  mons  veneris,  on  which  there  were  but  a  very  few 
hairs.  The  vagina  was  small  and  narrow,  with  a  well-marked  hymen.  The 
OS  and  cervix  uteri  were  absent,  but  on  rectal  examination  a  small  hard 
lump  was  detected  in  the  position  of  the  body  of  the  uterus.  The  ovaries 
could  not  be  felt.     In  addition,  she  had  bifid  sternum,  associated  with  con- 


^  Traite  de  Gyn.,  1884,  p.  947. 

"^  Med,  Chir,  Trans,,  vol.  xlvii.,  1864,  p.  195. 


36  MAMMARY    VARIATIONS     PER    DEFECTUM 

genital  malformation  of  the  heart,  the  exact  nature  of  which  could  not  be 
determined.  She  suffered  much  from  palpitation  of  the  heart,  cough,  and 
dyspnoea. 

Pears^^  has  related  the  case  of  a  dwarfed  woman,  aged  29,  who  was  only 
four  feet  six  inches  high.  Her  breasts  and  nipples  were  like  those  of  a 
male.  She  had  never  menstruated.  There  was  no  hair  on  the  pubes, 
nor  any  other  signs  of  puberty.  "  She  always  expressed  an  aversion  to 
young  men  who  were  too  familiar  with  her."  She  had  been  subject  to 
violent  fits  of  coughing  and  convulsions  for  several  years,  and  in  one  of 
these  she  died.  At  the  necropsy  the  uterus  was  of  the  infantile  type.  "  The 
ovaria  were  so  indistinct  as  rather  to  show  the  rudiments  which  ought  to 
have  formed  them  than  any  part  of  their  natural  structure. 

Analogous  instances  have  been  recorded  by  Baynharn,'"'** 
Caillot,^^  Renauldin,-^-  and  others. 

According  to  Puech,  the  infantile  condition  of  uterus,  that 
generally  goes  with  absent  or  rudimentary  ovaries,  is  nearly 
always  correlated  with  defective  mammary  development;^'^ 
when,  however,  the  uterus  is  really  absent,  the  mamma;  are,  as 
a  rule,  unusually  well  developed,  and  in  these  cases  the  ovaries 
are  generally  normal.^*  This  is  just  the  converse  of  what 
happens  in  males,  in  whom  absence  of  the  testes  is  usually 
associated  with  exaggerated  mammary  development. 

A  case  lately  reported  by   Beuttner^^  well  illustrates   the.se 

remarks. 

The  patient  was  a  healthy-looking  woman,  aged  18,  with  rudimentary 
uterus  bicornis  and  absence  of  vagina  ;  but  both  ovaries  existed,  though 
they  were  rather  large  and  tender.  The  mamm;€  and  pubic  hair  were  well 
developed.  She  had  never  menstruated.  Both  ovaries,  tubes  and  uterine 
horns  were  removed  by  abdominal  section.  The  ovaries  contained  normal 
follicles,  follicular  cysts  with  serous  or  blood-stained  fluid  contents,  and 
numerous  cicatrices  of  old  cysts,  &c.,  so  that  ovulation  had  evidently  gone 
on.     The  tubes  were  patent,  but  the  uterine  cornua  presented  no  lumina. 

It   follows  from  what  has  been  stated,  that  the  mammary 

development   is    dependent  upon   ovariaii   rather   than   uterine 


-"-'  Pliilosophical  Trans.  R.  S.,  Lond.,  1805,  p.  225. 
^  London  Medical  Gazette,  vol.  iii.,  1829,  p.  72.  • 

"  Mem.  de  la  Sac.  Med.  d'Ei/iulation,  Paris,  t.  ii.  (1798),  p.  270,  et  seq. 
^  Stances  de  I' Acad.  Roy.  de  Med.,  28  f^v.,  1826. 

'^  For    two   well    recorded    cases    confirmatory    of    tliis    view,    vide    Warren, 
'Surgical  Observations,"  Boston,  1867,  p.  305. 

*'  "  Les  ovaries  et  leurs  anomalies,"  Paris,  1873  ;  see  also  Op.  cit.,  p.  91. 
^'  Ceiit.f.  Gyu'dl;.,  No.  49,  1893. 


ATHELIA.  37 

integrity.     According  as  the  ovaries  are  well  or  ill  developed 
so  will  the  mammae  be. 

§    III. Athelia. 

Congenital  absence  of  the  nipple — athelia — is  much  com- 
moner than  any  of  the  foregoing  anomalies. 

Inasmuch  as  this  structure  is  formed  by  upheaval  of  the 

area  of  skin  perforated  by  the  ducts  of   the  nascent  gland,  it 

follows  that  in  true  athelia  none  of  the  nipple  structures — skin, 

connective  tissue,  vessels,  nerves,  ducts,  &c. — are  really  wanting, 

as  Duval  erroneously  supposed  ;  but  we  have  to  do  simply  with 

failure  of  the  normal  mammillary  outgrowth.     This  condition 

is  usually  unaccompanied   by  any  other   malformation,  and    it 

generally  affects  both  breasts. 

I  lately  saw  a  healthy  young  lady,  aged  i8,  with  marked  defect  of  this 
kind,  associated  with  eczema  of  the  malformed  parts.  Her  breasts  were 
large,  and  otherwise  well  developed ;  but  their  nipples  were  completely 
absent,  and  in  the  place  of  each  was  a  small  transverse  groove,  surrounded 
by  a  diminutive,  stunted  areola.  The  affection  dated  from  birth.  There 
was  no  family  history  of  any  similar  deformity.      Menstruation  was  normal. 

Analogous  cases  have  been  seen  by  Cruveilhier,^"  Davis,^'' 
and  many  others.  Persons  thus  affected  usually  have  plenty 
of  milk  during  lactation,  but  they  are  nevertheless  unable  to 
suckle  their  children. 

Like  other  forms  of  defective  mammary  development,  athelia 

is  sometimes    found  associated  with  imperfect  development  of 

the  genital  organs,  as  in  the  following  remarkable  case,  related 

by  Chambers.^* 

The  patient,  aged  24,  had  the  general  appearance  and  external  sexual 
organs  of  a  female,  including  the  well  developed  female  bust.  She  had 
always  passed  as  a  female,  having  been  engaged  as  a  housemaid.  Both 
nipples  were  completely  absent,  and  the  place  of  each  was  occupied  by 
a  small  rose-coloured  spot,  representing  the  areola.  There  was  no  hair  in 
the  pubic  region.     The  mons  veneris  was  ill  developed.     The  vagina  was 


^""  "Traite  d'Anatomie  Descript.,  ed.  1874,  t.  2"'«,  p.  525. 

■"  Medical  Times,  vol.  i.,  1852,  p.  250. 

■*'*   Trans.  Obslet.  Soc.  Loud.,  vol.  xxi.  (1879),  p.  256. 


3^  MAMMARY    VARIATIONS    PER    DEFECTUM. 

small,  and  ended  in  a  cul-de-sac^  and  there  was  no  trace  of  uterus  or  ovaries. 
Menstruation  had  never  taken  place  nor  had  molimina  ever  been  experi- 
enced. In  each  inguinal  region  there  was  an  irreducible  congenital  hernial 
tumour,  each  of  which  contained  a  firm  circumscribed  body,  thought  to  be 
an  ovary.  These  bodies  were  excised,  but  on  microscopical  examination 
after  removal  they  proved  to  be  testes. 

In  such  cases  as  the  foregoing  we  evidently  have  to  do  with 
defective  nipple  evolution  almost  ab  initio.  In  consequence, 
we  often  see  persistence  of  the  depression  which,  in  the  normal 
course  of  development,  marks  the  site  where  the  nipple  will 
subsequently  arise. 

When  the  morbid  process  supervenes  at  a  somewhat  later 
period,  then  we  get  some  of  the  various  minor  degrees  of  con- 
genital mammillary  imperfection  which  are  of  such  frequent 
occurrence  :  thus  the  nipple  may  be  small,  stunted,  flat- 
tened, short,  depressed,  umbilicated,  or  quite  invaginated,  or 
otherwise  malformed.  Such  conditions  are  fruitful  sources  of 
trouble  during  lactation  ;  they  are,  indeed,  one  of  the  chief 
causes  of  the  acute  inflammations  and  abscesses  so  common 
at  that  period.  According  to  Birkett,^^  out  of  97  cases  of 
acute  mammary  abscess,  there  was  imperfect  mammillary  de- 
velopment in  48,  or  in  half  the  total  number.  Congenital 
imperfection  of  the  nipple  is  often  found  in  association  with 
neoplasms  {(j.  v.  ch.  xii.,  §1).  The  alleged  examples  of  imper- 
forate nipples  of  congenital  origin  are  by  no  means  convinc- 
ing; if  this  condition  really  exist  it  has  yet  to  be  demonstrated. 
Absence  or  defect  of  the  nipple  is  not  infrequently  caused  by 
traumatisms  or  diseases  in  the  newly  born,  such  as  bites,  burns, 
wounds,  abscesses,  ulcers,  &c. 

When  the  nipple  is  deficient,  the  areola  is  often  stunted  or 

absent;  but  it  is  rare  to  find  the  areola  absent  when  the  nipple 

is  well  formed,  as  in  the  following  case  by  O'Flynn.^^ 

A  healthy-looking  woman,  aged  30,  the  mother  of  seven  children,  who, 
when  siie  came  under  observation,  was  pregnant  for  the  eighth  time. 
Her  breasts  were  small  and    flaccid  like  those  of  a  girl   at  puberty,  and 

*'  Art.  "  Diseases  of  the  Breast,"  Ilulmes'  "System  of  Surgery,"  vol.  iii.  (1883), 
P-  435- 

'"  Dublin  Medical  Press,  vol.  liv.  (1S65),  p.  J 12. 


INVOLUTION    ATROPHY,    ETC.  39 

during  her  previous  pregnancies  they  had  never  enlarged  nor  given  any 
milk.  The  nipples  were  prominent,  but  neither  of  them  had  an  areola. 
Her  mother's  breasts  were  rudimentary,  and  though  she  had  eleven 
children,  no  milk  was  ever  secreted. 

Anomalies  of  this  kind  are,  however,  fairly  common  in 
connection  with  supernumerary  mammillary  structures. 

S     IV. Involution  atrophy,  &c. 

At  the  climacteric  period  the  breasts  normally  undergo 
atrophic  changes,  which  usually  affect  the  fibro-fatty  as  well  as 
the  glandular  elements.  The  degree  to  which  this  involution 
takes  place,  and  the  age  in  which  it  sets  in,  are  variable. 
Occasionally  these  changes  begin  at  a  very  early  period  of 
life,  and  proceed  to  such  a  degree  as  to  constitute  veritable 
disease. 

A  well-marked  instance  of  this  affection  lately  came  under  my  notice 
in  the  person  of  a  young  widow,  aged  ^o,  both  of  whose  breasts  were  small 
and  flaccid,  like  those  of  a  thin  old  woman.  Before  the  death  of  her 
husband,  two  years  previously,  she  had  a  well-formed  bust  ;  but  since  then 
the  breasts  had  gradually  wasted  away.  Her  general  health  was  good, 
but  she  was  less  plump  than  formerly.  The  catamenia  were  scanty,  but 
regular.  Shortly  after  the  death  of  her  husband  she  lost  her  only  child. 
Here  grief,  and  suppression  of  the  sexual  function,  seem  to  have  been  the 
determining  causes. 

Another  somewhat  similar  case^'  is  that  of  a  married  lady,  aged  24, 
who  had  noticed  her  breasts  wasting  away  for  four  months.  They  were 
formerly  well  developed,  and  she  knew  of  no  cause  for  their  atrophy.  The 
general  health  was  good,  there  was  no  organic  disease,  and  menstruation 
was  normal.  On  examination  the  mammae  were  found  very  atrophied. 
She  had  been  married  for  two  years,  and  one  year  after  marriage  gave 
birth  to  a  child,  which  died  a  few  weeks  afterwards  of  bronchitis. 

In  sterile  women,  and  in  those  who  have  neglected  to  suckle 
their  offspring,  the  mammae  often  shrink  to  quite  small  pro- 
portions. 

Reynolds^-  has  given  an  account  of  a  woman,  aged  21,  who,  having 
suckled  her  first  child  only  for  a  few  weeks,  soon  afterwards  saw  both  her 
breasts  completely  disappear,  so  that  not  a  vestige  of  them  could  be  felt. 
Yet  when  she  became  pregnant  again,  they  both  enlarged  to  a  fair  size  and 


"  Lancet,  vol.  i.,  1884,  p.  782 
'■'  Ibid.,  p.  331. 


40  MAMMARY    VARIATIONS    PER    DEFECTUM. 

gave  milk  ;  but,  as  she  neglected  to  suckle,  the  glands  soon  wasted  away 
as  before— and  so  after  each  pregnancy. 

There  can  be  no  doubt  that  the  habit  of  weaning  children 
does  in  the  long  run  tend  to  defective  mammary  development. 
Disuse  leads  to  atrophy  and  the  result  is  inherited.     De  Sinety^^ 
says  he  has  seen  examples  of  this  in  the  women  of  families 
whose  children  have  been  weaned  for  several  generations  ;  and 
in  two  instances,  although  very  prolific,  they  were    unable   to 
suckle,  through  failure  of  lacteal  secretion.       In  an  interesting 
essay  on  this  subject  Altmann**  tells  us  that  very  few  of  the 
peasant  women  of  the  table-lands  of  Bavaria  and  Swabia  have 
sufficient  milk  for  suckling  their  children.     Among  them    the 
custom  of  rearing  by  hand  is  almost  universal ;    consequently 
their  infant  mortality  is  very  high.     He  examined  the  mammae 
of  thirty  of  these  women,  and  compared  them  with  the  mammae 
of   Silesian    peasant  women,  who   always    suckle  their  infants. 
He  found  that  the  former  set  of  glands  were  much  the  smaller. 
In  only  eight  of  the  Bavarian  specimens  did  the  weight  of  the 
gland  exceed   lOO  grammes ;   the  normal  weight,  according  to 
Hennig,  being  from    i6o  to    556    grammes.       On   histological 
examination  of  sections  from  the  two  sets  of  specimens  marked 
differences  were  noticeable.     In  the  Bavarian  glands  the  acini 
and  small  ducts  were  scanty  and  ill  developed,  and  the  fibrous 
stroma  was  unduly  abundant ;    whereas  in  the  Silesian  glands 
acini  and  tubuli  were  well  developed,  and  the  stroma  was  less 
abundant  and  dense.     Altmann  does  not  hestate  to  ascribe  this 
atrophic  condition  of  the  Bavarian  mammae  to  hereditary  influ- 
ence, owing  to  the  custom  of  weaning  having  prevailed  for  many 
years.      Reinhold*'  has  also  ably  investigated   this   interesting 
subject  with  similar  results. 

Atrophy  of  the  ovaries,  and  morbid  conditions  interfering 
with  their  integrity,  at  comparatively  early  periods  of  life 
induce   somewhat   similar   conditions. 


'•'   Trait c  de  Gyii.,  p.  918. 

"  Anh.  f.  path.  Anat.,  Bd.  cxi.,  1888,  s.  31J 

'*  Arch,  f.  path.  Anat.,  Bd.  cxi.,  lift.  2. 


INVOLUTION    ATROPHY,     ETC.  4 1 

Thus  in  Potts'^^  well-known  case,  the  catamenia  became  suppressed,  the 
mammce  wasted,  and  the  body  got  thinner  in  a  healthy  and  plump  young 
woman,  aged  23,  each  of  whose  ovaries  presented  as  a  hernial  swelling  at 
the  inguinal  rings  ;  and  were  excised  in  consequence  of  their  incapacitating 
the  patient  from  work. 

According  to  most  oophorectomists,''"  extirpation  of  the 
ovaries  in  adult  human  females  is  seldom  followed  by  marked 
mammary  atrophy,  or  the  loss  of  feminine  qualities,  other  than 
those  of  menstruation  and  procreation.  Keppler,'^^  however, 
distinctly  states  that  in  most  of  his  castrated  patients,  the 
breasts  subsequently  wasted,  and  tended  to  revert  to  the  male 
type.  The  truth  seems  to  be,  that  when  the  essential  sexual 
organs  are  removed  early  in  life,  before  the  secondary  sexual 
characters  have  become  thoroughly  well  established,  the  latter 
subsequently  abort  ;  whereas  when  the  removal  of  these  organs 
is  deferred  until  the  secondary  sexual  characters  have  become 
well  established,  then  the  latter  generally  persist,  provided 
that  the  patient  is  still  in  the  prime  of  sexual  hfe.  Under 
these  circumstances  Schwinzinger's^^  suggestion  that  castration 
should  be  practised  to  bring  about  atrophy  of  the  mammae 
in  order  to  prevent  the  development  of  cancer,  or  its  recur- 
rence after  operation,  can  hardly  be  taken  seriously. 

Several  cases  have  been  recorded  showing  that  mammary 
atrophy  may  sometimes  be  due  to  hereditary  syphilis.  The 
patients  thus  affected  are  generally  otherwise  defective  in  sexual 
and  general  development.  Claude,^"  Fournier^^  and  Rivington'^^ 
have  especially  directed  attention  to  this  subject. 

Other  alleged  causes  of  mammary  atrophy  are  prolonged 
and  excessive  suckling,  exhaustive  illnesses,  and  the  frequent 
internal  administration  of  iodide  of  potassium  in  large  doses. 

In  the  treatment  of  mammary  atrophy,  frequent  and  regular 

'"  "Surgical  Works,"  vol.  iii.,  p.  329. 

"  Battey,  R.,  Arii.  Syst.  Gyn.,  vol.  ii.,  1S88,  p.  849. 

''  Ann.  de  Gyn.,  Oct.,  1890. 

•"  Report  Berlin  Congress,  April  25,  1889. 

«"  These  de  Paris,  1886. 

■'^'   "  Le9ons  sur  la  syphilis  hereditaire  tardive,"  1886. 

■'■"'  Med.  Times  and  Gaz.,  Oct.  19,  1872,  p.  433. 


42  MAMMARY    VARIATIONS    PER    DEFECTUM. 

suction  of  the  nipples,  by  mouth  or  with  an  apparatus,  is  the 
most  likely  means  of  succeeding ;  together  with  massage  of  the 
breasts,  ovarian  and  spinal  regions.  Suction  of  the  nipples, 
as  previously  mentioned,  is  a  most  powerful  stimulus  to 
mammary  activity,  for  it  is  known  to  have  induced  lactation  in 
non-pregnant  multiparae,  and  even  in  virgins.  The  internal 
administration  of  mild  stimulating  tonics,  and  aphrodisiacs 
should  be  combined  with  the  local  treatment.  When  syphilis 
is  suspected  the  local  application  of  mercurial  ointment,  with 
iodide  of  potassium  internally,  is  recommended,  together  with 
good  feeding. 


43 


CHAPTER  IV. 

Polymastia,  with  special  reference  to  "  Mamm^  Er- 
ratic^e,"  and  the  development  of  neoplasms  from 
Supernumerary  Mammary  Structures. 


S     I. Phylogenetical. 

Human  beings  usually  have  but  a  single  pair  of  mammary 
glands,  which  are  situated  on  the  ventral  aspect  of  the  thorax 
(^pectoral),  as  in  apes,  bats,  elephants,  and  a  few  other  mammals. 
This  is  the  smallest  number  normally  met  with  throughout  the 
group.  Most  mammals  have  several  pairs  of  such  glands, 
situated  at  various  points  of  the  ventral  surface  of  the  trunk ; 
and,  as  a  rule,  there  is  a  certain  relation  between  their  number 
and  the  number  of  young  brought  forth  at  a  birth,  the  former 
being  twice  as  numerous  as  the  latter.  In  the  insectivorous 
order,  which  yields  the  largest  number,  there  may  be  as  many 
as  eleven  pairs,  and  there  are  seldom  fewer  than  seven.  In  these 
cases  the  glands  extend  along  the  whole  length  of  the  ventral 
surface,  in  two  nearly  parallel  rows,  from  the  axillary  to  the 
inguinal  regions.  I  said  nearly  parallel,  because  the  two  rows 
converge  towards  the  inguinal  regions.  In  the  lowest  mamma- 
lians (monotremes,  marsupials,  &c.) — which  represent  the  primi- 
tive type— the  mammae  are  as  a  rule  exclusively  inguinal ;  in  the 
highest  class  they  are  almost  invariably  pectoral  ;  whilst  animals 
with  abdominal  mammae  occupy  an  intermediate  position. 

In  human  beings  any  diminution  of  the  normal  number  is 
very  exceptional ;  but  it  is  by  no  means  uncommon  to  find  their 
number  increased.  When  this  does  occur,  it  is  a  significant  fact 
that  the  additional  mammary  structures  do  not  develop  just  any- 
where ;  but  they  appear  only  in  certain  definite  positions,  which 


44  POLYMASTIA. 

almost  invariably  correspond  with  those  occupied  normally  by 
the  glands  of  polymastic  animals.  Such  facts  warrant  us  in 
attributing-  their  origin  to  reversion  ;  and  they  imply  the  exist- 
ence in  the  past  of  a  polymastic  atavtis,  accustomed  to  produce 
several  young  at  a  birth.  The  transition  from  polymastism  to 
bimastism  may  now  be  seen  going  on  in  the  Lemurs,  whose 
inguinal  and  abdominal  mammse  are  aborting,  so  that  only  a 
single  pair  of  pectoral  ones  tends  to  be  well  developed  ;  and  this 
change  has  been  correlated  with  diminution  of  the  number  of 
young  brought  forth  at  a  birth.  Similarly  in  many  marsupials 
it  has  been  observed  that  more  nipples  are  found  in  the  foetal 
than  in  the  adult  state  :  some  of  these  structures  atrophy,  whilst 
others  develop.  "  On  the  whole,"  says  Darwin,^  "  we  may  doubt 
if  additional  mammse  would  ever  have  been  developed  in  both 
sexes  of  mankind,  had  not  man's  early  progenitors  been  provided 
with  more  than  a  single  pair." 

I  think  it  would  conduce  much  to  a  more  complete  under- 
standing of  the  subject  if  I  could  give  a  sketch  of  the  mammary 
arrangement  of  these  early  progenitors.  According  to  Meckel 
von  Hemsbach,  human  beings  originally  had  five  mammse  :  a 
pair  corresponding  to  the  normal  pectoral  ones,  one  in  each 
axilla,  and  a  median  one  just  below  the  sternum.  I  suppose 
the  author  must  have  based  this  idea  of  his  on  some  cases  he 
had  seen,  in  which  the  glands  really  had  this  distribution  ;  but 
I  have  been  unable  to  find  the  record  of  any  such  case.  Modern 
investigations  have  discredited  this  conception  of  Meckel's.  In 
the  numerous  well-recorded  cases  of  supernumerary  mammary 
structures  now  available,  there  are  ample  materials  for  recon- 
structing the  mammary  arrangement  or  the  ideal  human  atavus 
on  a  really  scientific  basis.  From  this  source  it  may  be  gathered 
that  our  early  progenitors  had  at  least  seven  pairs  of  mammae 
on  the  ventral  aspect  of  the  trunk ;  of  these  only  the  present 
pectoral  pair  have  survived.  Of  the  six  lost  pairs  three  were 
situated  above  and  external  to  the  present  normal  pair,  and 
three  below  and  internal  to  them  (fig.  lo). 


"  Duscenl  of  Man  "  (I879),  p.  n. 


PHYLOGENETICAL. 


45 


On  careful  consideration  of  all  the  facts  known  to  me 
relative  to  the  distribution  of  mammae  in  human  beings  and 
animals  under  normal  and  abnormal  conditions,  it  seems  prob- 
able that  the  mammae  were  originally  segmental  organs — a  pair 
being  developed  on  the  ventral  aspect  of  each  somite.  In  con- 
firmation of  this  view  the  following  cases  may  be  cited  : — 


Fig.  io. — Diagram  showing  the  mammary  arrangement  of  man's  early  progenitors. 


In  Neugebauefs.,  with  eight  supernumerary  nipples,  the  largest  number 
yet  observed  in  any  human  being,  three  pairs  were  situated  above  the 
normal  mammae,  in  positions  identical  with  those  figured  in  my  diagram. 
The  other  two  nipples  were  situated  below,  and  internal  to  the  normal  pair  ; 
that  on  the  right  side  was  placed  immediately  below  the  bosom,  that  on  the 
left  side  was  some  inches  lower  dowii.  These  unsymmetrical  nipples  must 
not  be  regarded  as  a  pair  ;  the  upper  one  evidently  represents  the  right 
nipple  of  the  fifth  pair  of  my  diagram,  and  the  lower  one  the  left  nipple  of 
my  sixth  pair. 


46  POLYMASTIA. 

In  Ainmoiis  case  there  were  three  pairs  of  supernumary  mammillary 
structures.  One  pair  was  situated  above  the  normal  nipples  and  external  to 
them,  over  the  middle  of  the  anterior  axillary  border,  in  a  position  corres- 
ponding to  the  second  pair  of  my  diagram.  The  other  two  pairs  were  placed 
below,  and  rather  internal  to  the  normal  ones.  Of  these,  the  lowest  pair 
was  situated  close  to  the  costal  margin,  in  the  position  of  the  sixth  pair  in 
my  diagram  ;  the  other  pair  was  situated  midway  between  these  and  the 
normal  ones,  corresponding  in  position  with  the  fifth  pair  of  my  diagram. 

In  Fitzgibboiis  case,  two  pairs  of  supernumerary  nipples  were  present ; 
one  pair  above  the  normal  mammas  corresponds  to  the  third  pair  of  my 
diagram  ;  and  the  other  pair,  below  the  normal,  answers  to  my  fifth  pair. 

In  Morttllefs  ca.s,&,  two  pairs  of  supernumerary  nipples  were  also  present, 
but  both  were  situated  below  the  normal  breasts  ;  the  lower  pair  occupied 
the  upper  part  of  the  abdomen,  in  a  position  which  corresponds  with  the 
seventh  pair  of  my  diagram  ;  the  upper  pair  was  situated  between  the 
normal  mammns  and  the  abdominal  pair,  probably  in  the  position  of  the 
fifth  pair  of  my  diagram,  but  as  to  this  the  author's  description  lacks  defini- 
tion. 

In  Alexander's  case,  there  were  also  two  redundant  pairs  of  nipples, 
below  the  normal  pair,  in  similar  situations  to  Mortillet's. 

The  other  cases  of  supernumerary  mammary  structures 
occupying  positions  corresponding  to  those  figured  in  my 
diagram,  may  be  classed  as  follows  : — 

First  pair  {2i^\\\diry).  Cases  by  Leichtenstern,  D'Outrepont, 
Perreymond  and  Godfrain. 

Second  pair  (middle  of  anterior  axillary  border).  Cases  by 
Quinquad,  Bruce  and  Charpentier. 

Third  pair  (just  above  and  slightly  external  to  the  normal 
female  bosom).  Cases  by  Shannon  (fig.  14),  Lee,  Gardiner,  and 
Champneys. 

Fourth  pair  {\he  normal  mammae). 

Fifth  pair  (just  below  and  slightly  internal  to  the  normal 
female  bosom).  More  than  three-fourths  of  all  instances  of 
supernumerary  mammary  structures  have  been  found  in  this 
position.  Typical  examples  of  the  development  of  this  pair 
of  mammae  in  women  have  been  recorded  by  Leichtenstern 
(fig.  13),  Whitford,  Chatard,  and  many  others  ;  and  in  men  by 
Max  Bartels,  Handysidc  and  myself  (fig.  12). 

Sixth  pair  (below  and  slightly  internal  to  the  preceding,  near 
the  costal  margin).  Cases  in  men  by  Ammon,  Leichtenstern 
and  Hamy,  and  in  women  by  Rapin,  De  Sin^ty,  &c. 


MAMM^     ERRATICS.  47 

Seventh  pair^  (below  and  slightly  internal  to  the  preceding, 
on  the  upper  part  of  the  abdomeii).  Cases  by  Tarnier,  Bar- 
tholin, Bruce  and  Alexander. 

Further  on  details  will  be  given  of  most  of  the  cases  above 
referred  to.  Supernumerary  mammae  appearing  in  any  of  the 
above  positions  must,  for  the  reasons  before  mentioned,  un- 
doubtedly be  regarded  as  true  reversions. 

S     II. Mammae  Erraticae. 

It  is  an  exceedingly  rare  thing  for  redundant  mammary 
structures  to  be  found  in  any  other  part  of  the  body.  Of  i66 
cases  collected  by  Leichtenstern^  and  Bruce,*  there  were  only 
four  instances  of  the  kind  i^mammce  erraticce)^  and  they  are 
certainly    rarer   even    than    this. 

I  now  propose  to  examine  these  cases,  and  other  similar 
ones  since  recorded,  with  a  view  to  determining  their  real 
significance.  Considering  the  great  similarity  between  the  con- 
dition resulting  from  chronic  fistula  in  connection  with  sebaceous 
and  dermoid  cysts  that  have  undergone  suppuration,  which 
extends  even  to  the  production  of  a  milk-like  fluid,  and  several 
of  the  alleged  cases  of  inammce  erraticcE,  I  think  the  latter  ought 
to  be  very  critically  examined  before  they  are  definitely  accepted 
as  such. 

These  remarks  are  especially  applicable  to  the  two  cases  of 
so-called  dorsal  mammcz,  of  which  the  records  are  ancient  and 
very  imperfect.  For  instance,  all  the  information  we  have  of 
the  case  mentioned  by  Paulinus,^  is  as  follows  : — 


2  McGillicuddy's  case  (M  F.  Med.  Record,  Oct.  lo,  1891)  with  a  pair  of  rudi- 
mentary abdominal  mammary  structures  at  about  the  level  of  the  umbilicus — in  a 
man  aged  35 — seems  to  indicate  that  the  atavus  had  a  second  pair  of  abdominal 
mammse,  lower  down  than  the  seventh  pair  of  my  diagram.  It  accords  with  this 
that  there  is  in  St.  Bartholomew's  Hospital  Museum  (series  xxxviii.,  No.  32  A)  a 
drawing  of  the  body  of  a  man  with  a  single  redundant  abdominal  nipple  and  some 
subjacent  swelling,  at  about  the  level  of  the  umbilicus  and  external  to  it. 

3  Arch.f.  path.  Anat.,  Bd.  Ixxiii.  (1878),  s.  222. 
*  Journal  of  Anatomy,  vol.  xiii.  (1879),  p.  425, 

^  "Obs.  med.-phys.  select,"  in  the  Miscel.  Curios.  Acad.  med.  phys.  nat.  czirios., 
an.  iv.,  p.  203,  in  the  appendix. 


48  POLYMASTIA. 

"Rustica  foemirta  e  comitatu  Winzemborch  prteter  duas  in  loco  ordinario 
adhuc  duas  alias  ejusdem  quantitatis  et  qualitatis  mammas  lacte  foecundas, 
habuit  e  regione  in  tergo.  Jam  tertia  vice  peperat  gemellos,  qui  ante 
retroque  suxerunt." 

The  account  of  Helbig's*^  case  is  still  more  unsatisfactory. 

"  B.  Salewsky,  nobilis  Polonus,  vir  fide  dignus  in  insula  Macassar 
(veteribus  Celebes)  mulierum  vidit  quie  mammas  duas  in  dorso  habens, 
eas  sub  axillis  protractas  infanti  debat  et  firmiter  asserebat  integro  con- 
sanguinearum  suarum  numero  banc  monstrositatem  esse  propriam."' 

It  is  very  well  for  such  cases  to  be  in  the  mind  of  the 
scientist ;  but  until  confirmed  by  modern  observation  they  ought 
not  to  be  regarded  as  an  integral  part  of  our  science. 

In  this  connection  it  may  be  well  to  recall  the  fact  that  in  a 
few  animals  the  mammae  normally  have  a  dorsal  position  ;  e.g., 
Myopotanms  coypus'  (near  the  dorsal  spine),  Capromys  foiu'iiieri^ 
(behind  each  axilla),  and  Lagostonius  trichodactyliis  (dorso- 
lateral aspect  of  thorax). 

Barth^  has  recorded  a  very  remarkable  case  of  alleged 
"  mamma  erratica  "  on  the  face. 

The  patient  was  a  slender  blonde,  aged  20,  who  had,  just  in  front  of  the 
lower  part  of  her  right  ear,  a  peculiar  wart-like  growth  surrounded  by  a  pig- 
ment and  a  few  hairs.  It  was  erectile,  and  looked  very  like  a  nipple.  The 
patient  said  it  generally  enlarged  during  menstruation,  and  that  it  had 
existed  as  long  as  she  could  remember.  She  had  a  somewhat  similar  growth, 
which  also  enlarged  during  menstruation,  above  her  nose  ;  and  several  pig- 
ment spots  on  various  parts  of  the  face,  as  well  as  a  large  one  at  the  lower 
edge  of  the  right  breast.  The  nipple-like  growth  on  the  face  was  excised. 
On  microscopic  examination  it  was  found  to  consist  chiefly  of  sebaceous 
idand  tissue,  which  was  not  embedded  in  the  subcutaneous  fat.  In  several 
of  the  sections  small  epithelial  pearls  were  seen,  and  cellular  collections  like 
small  sebaceous  cysts  ;  as  well  as  irregularly  arranged  groups  of  sweat 
"■lands,  and  bundles  of  unstriated  muscle  fibres.  A  few  ducts  were  observed, 
but  none  could  be  traced  to  the  nipple-like  process.  Waldeyer,  who 
examined  the  histological  preparations,  advised  giving  no  positive  opinion 
as  to  the  real  nature  of  the  disease  ;  and  the  title  of  Barth's  essay,  '•'•  Eine 
eigenthiimliche  Warze  nahe  der  Ohrmuschel"  suggests  that  the  author  him- 
self was  in  doubt. 

I  have  several  times  seen  similar  histological  appearances  in 


"  Op.  cit.,  an.  i.\.  and  x.,  p.456. 

■  Proc.  Zool.  Soi.  (Christy),  1 835,  p.  1 82. 

'  Cuvier,  (J.,  Lefotis  li^Anat.  ComJ>.,  t.  viii.,  p.  606  (lecoii  jSe). 

^  A7'c/i.  f.  path.  Anat.y  B<1.  cxii.  (1888),  s.  569. 


MAMM/li    ERRATIC.-^.  49 

connection  with  congenital  malformations  of  the  skin  of  the  face 
(warty  moles)  ;  and  I  am  inclined  to  regard  the  case  as  belong- 
ing to  this  category,  rather  than  to  that  of  "  inamnia  erratica." 

The  case  of  accessory  mamma  near  the  acromion,  recorded  by 
Klob/°  may  be  regarded  as  an  unusual  form  of  reversion  ;  for, 
as  Beddard^^  has  shown,  in  Hapalemur  grisens,  mammae  are  of 
normal  occurrence  in  this  locality ;  as  they  are  also  in  certain 
pachystomatous  Cheiroptera.^-  In  one  of  Champney's^^  cases,  a 
lying-in  woman  had  a  supernumerary  mammary  structure  in 
each  axilla,  the  size  of  a  pigeon's  egg,  which  opened  by  a  single 
pore  at  the  middle  of  the  anterior  axillary  fold.  From  the 
glandular  body  in  the  right  axilla  a  tail  zvas  prolonged  dozvn  the 
arm  for  nearly  an  inch. 

Klob's  patient  was  a  man,  and  the  supernumerary  gland  presented  as  a 
conical  swelling,  the  size  of  a  walnut,  just  below  the  left  acromion,  over  the 
convexity  of  the  deltoid  muscle.  It  had  a  rudimentary  nipple,  but  no 
areola.  Microscopic  examination  revealed  acinous  gland  tissue  like  that  of 
the  normal  mamma. 

Puech^'  refers  to  a  case  by  Scalzi,  from  an  Italian  source,  in  which  an 
aged  woman,  who  was  admitted  into  hospital  for  a  scalp  wound,  was  found 
to  have  a  rudimentary  supernumerary  mamma  on  the  right  shoulder,  near 
the  axilla,  and  another  below  the  left  breast.  Her  daughter  had  a  super- 
numerary milk-giving  mamma. 

An  analogous  case,  in  the  lower  limb,  has  been  recorded  by 
Robert  of  Marseilles. 

The  patient  was  a  v^^oman,  aged  50,  with  a  supernumerary  milk-giving 
mamma  on  the  outer  side  of  the  upper  part  of  the  left  thigh,  4  inches  below 
the  great  trochanter.  The  case  was  examined  and  reported  upon  by 
Magendie,''''  for  the  French  Academy  of  Science.  The  real  nature  of  the 
supernumerary  gland  was  only  discovered  after  her  first  confinement,  when 


•»  ZeitscJir.  d.  K.  K.  GeselhcJi.  d.  Aerzte  z.  Wien  (1858),  N.F.I.,  No.  52,  s.  815. 

"  Proc.  Zool.  Soc,  1884,  p.  394.  Although  the  specimen  to  which  the  description 
relates  is  a  male,  well-developed  mammary  glands  were  found  to  exist.  The  aper- 
tures of  these  glands  were  upon  the  upper  part  of  the  arm  ;  and,  on  removing  the 
skin,  the  glands  themselves  were  found  to  be  attached  by  .membrane  to  the  pictoralis 
major,  the  biceps,  and  part  of  the  deltoid  muscles. 

'"  Milne-Edwards,  H.,  Lepns  sur  V Anat.  Comp.,  Szc,  t.  ix.  (1870),  p.  132. 

'^  Afed.  Chir.  Trans.,  vol.  Ixix.  (1886),  p.  434. 

"  Puech,  "  Les  mamelles  et  leurs  anomalies,"  Paris,  1876,  pp.  72  and  117. 

'^  Jozir.  Gen.  de  Mai.,  t.  c.  (1827),  p.  57. 

4 


50  POLYMASTIA. 

it  attained  the  size  of  half  a  lemon,  and  secreted  milk.  She  had  previously 
noticed  in  this  situation,  "un  petit  corps  arrondi  qui  a  toujours  ete  le  siege 
de  doulours  et  de  demangeaisons,  commes  les  seins  memes  aux  epoques  de 
ses  regies."  The  gland  had  a  nipple,  like  the  normal  ones,  so  that  she 
could  suckle  her  children  as  well  with  it  as  with  them.  Strange  to  relate, 
this  woman's  mother  had  a  supernumerary  pectoral  mamma  on  the  right 
side. 

The  position  of  the  redundant  gland  in  this  case  reminds  us 
of  the  so-called  glandida  fevioralis  of  the  male  Oniiikorhynchus  ; 
of  Caproviys  fouriiieri,  which  has,  in  addition  to  a  mamma  be- 
hind each  axilla,  two  others  "  en  avant  des  cuisses,  tout  a  fait 
sur  le  cote  et  plus  pres  du  dos  que  du  ventre ; "  ^'^  and  of  the 
Mare^"^  and  Ass,  which  have  the  mamm?e  in  the  groins,  far  in 
front  of  the  vulva. 

Here  also  it  seems  tolerably  certain  that  we  have  to  do  with 
an  aberrant  form  of  reversion. 

Roberts'  case  has  often  been  erroneously  cited  as  an  ex- 
ample of  inguinal  mamma — a  condition  which,  according  to 
Leichtenstern,  has  never  been  observed  in  any  human  being. 

Testut'*  has,  however,  lately  published  the  history  of  a  woman  in  whom, 
soon  after  her  confinement  at  the  Bordeaux  Lying-in  Hospital,  he  noticed  a 
true  supernumerary  mamma,  on  the  antero-internal  aspect  of  the  right 
thigh,  65  mm.  below  the  fold  of  the  groin,  and  in  a  vertical  line  with  the 
pubic  spine.  It  presented  as  a  rather  small,  irregular,  bossy  swelling, 
immediately  beneath  the  skin,  and  it  felt  just  like  the  normal  gland.  Its 
summit  was  surmounted  by  a  conical  nipple,  in  the  vicinity  of  which  were 
several  small  pigmentary  tdches.  The  patient  was  41  years  old,  and  other- 
wise well  formed.  The  pectoral  mammae  were  normal,  the  right  being 
rather  the  larger.  She  first  noticed  the  crural  structure  when  about  20 
years  old,  on  account  of  it  becoming  painful  during  menstruation.  At  each 
of  her  five  confinements  it  increased  in  size,  so  that  she  could  hardly  walk, 
on  account  of  its  rubbing  against  her  other  thigh.  She  never  noticed  that 
milk  escaped  from  it  during  lactation,  and  when  she  was  seen  by  Testut, 
several  months  after  her  last  accouchement,  lactation  had  ceased  and  no 
discharge  from  the  crural  structure  was  noticeable. 

As  previously  mentioned  mammae  exclusively  inguinal  are 
typical  of  the  lowest  mammalian  orders.     Among  the  highest 

'"  Milne-Edwards,  Op.  cit.,  p.  132. 

"  Naturalists  were  long  at  a  loss  to  discover  the  glands  of  the  horse  in  the  male, 
until  at  last  they  were  found  by  Buffon,  in  connection  with  the  sheath  of  the 
penis. 

'"  Bull,  de  la  Soc,  d'Anlhropologie,  ser,  iv.  ;    t.  ii.,  1891,  p.  757. 


MAMM/E    ERRATIC.^t.  5  I 

orders,  rudimentary  inguinal  mammae  are  occasionally  present 
as  in  the  RJiinolopJiidce,  although  all  other  Cheiroptera  have 
long  since  lost  all  trace  of  their  inguinal  mammse.  In  some 
Lemurs,  in  the  Aye-Aye,  and  in  many  other  animals,  mammae 
arc  of  normal  occurrence  in  the  inguinal  regions.  The  above 
case  seems  to  indicate  that  in  human  beings  reversion  may 
occasionally  reproduce  this  very  ancient  ancestral  mammary 
arrangement. 

Hartung's  ^^  case  is  evidently  nearly  allied  to  the  foregoing. 
Here  a  supernumerary  mamma  was  situated  in  the  left  labmm 
majns. 

The  patient,  a  woman  aged  30,  who  was  suckHng  her  child,  had  a  pedun- 
culated tumour,  the  size  of  a  large  goose's  egg,  attached  to  the  lower  and 
inner  part  of  the  left  labium  viajiis.  It  was  covered  over  with  skin,  and  its 
pedicle  was  the  size  of  a  man's  thumb.  In  front,  at  its  upper  part,  there 
was  an  eroded  ovoid  patch,  from  which  milk-like  fluid  escaped.  The 
patient  said  she  had  noticed  the  tumour  for  several  years  ;  and  that  it  had 
lately  got  much  larger.  It  was  freely  excised  with  the  pedicle,  and  during 
the  operation  a  considerable  quantity  of  milky  fluid  escaped.  On  examina- 
tion after  removal,  a  flattened  rounded  prominence,  like  a  retracted  nipple, 
could  be  made  out  in  the  centre  of  the  eroded  area;  and  surrounding 
this  was  a  shallow  depression.  At  the  summit  of  this  prominence  were 
several  small  orifices,  some  of  which  admitted  a  probe  ;  they  were  ducts 
which  radiated  into  the  tumour  substance.  It  was  obviously  a  rudimentary 
malformed  nipple,  with  its  areola.  The  rest  of  the  tumour  consisted  of  two 
gland-like  masses,  the  smaller  one  about  the  size  of  a  walnut  ;  on  micro- 
scopic examination  these  were  seen  to  be  composed  of  acinous  glandular 
structure,  lined  with  sub-cylindrical  epithelium,  just  like  that  of  the  normal 
mamma.  In  the  region  of  the  rudimentary  nipple  were  numerous  ducts 
lined  with  cubical  epithelium.  The  pedicle  consisted  of  fibro-fatty  tissue 
and  vessels.  From  the  careful  description  given  of  this  case  it  seems 
impossible  to  doubt  that  we  here  have  to  do  with  a  true  supernumerary 
mamma. 

In  most  Cetaceans  the  mammae  normally  occupy  a  some- 
what similar  position  ;  and  a  little  insectivorous  animal  {^Sorex 
crassicatidatus),  in  addition  to  two  pairs  in  the  groins,  has  a 
third  pair  under  the  base  of  the  tail,  at  the  level  of  the  anus.^'' 


'"  "  Ueber  einen  fall  von  Mamma  Accessoria,"  Inajig.  Diss.  Erlangen,  1875. 
-"  Cuvier,  Op.  cit.,  p.  606. 


52 


POLYMASTIA. 


In  a   very  few   cases   supernumerary  mammary  structures 
have  been  found  in  the  median  line  of  the  front  of  the  body. 


Fig.  II. — Median  nipple. 


I  lately  saw  a  man  (fig.  ii)  aged  67,  with  recurrent  epithelioma  of  the 
lower  lip,  who  had  a  well  marked  supernumerary  mammary  structure,  the 
size  of  a  shilling,  over  the  lower  part  of  the  sternum,  at  two  inches  below 
the  level  of  the  normal  nipples.  The  central  part  of  this  structure  presented 
a  conical  elevation,  just  like  a  nipple,  of  dark  brown  colour,  and  devoid  of 
hair;  around  this  was  a  pinkish  brown,  tuberculated  areola,  whence  numer- 
ous long  hairs  grew.  No  subjacent  gland  could  be  felt.  The  normal 
mammae  were  large  and  movable,  like  those  of  a  middle-aged  woman 
{gyftacomasiia).  At  about  four  inches  below  the  left  nipple  and  rather 
internal  to  it,  was  a  small  supernumerary  nipple  surrounded  by  a  few  hairs, 
but  devoid  of  areola.     The  patient  was  under  the  care  of  Dr.  Purcell. 

In  a  case  mentioned  by  McGillicuddy,-'  a  female  child  7  weeks  old,  is 
said  to  have  had  a  supernumerary  mammary  structure,  over  the  sternum, 
rather  above  the  level  of  the  normal  glands.  Sutton-  appears  to  have  met 
with  a  somewhat  similar  condition.  The  mammary  glandular  nature  of 
the  structures  in  these  two  cases  appears  to  me  doubtful. 

Gorrd-^  refers  to  a  Wallachian  vivandidre,  the  mother  of  two  children, 
who  died  shortly  after  the  birth  of  her  second  child  from  the  effects  of 
exposure  and  privation.  On  examining  her  body  after  death  Gorre  was 
surprised    to   find    a   well-developed    pair   of    supernumerary   milk-giving 


2'  New  York  Medical  Record,  October  10,  1891,  p.  448. 
*^  Illustrated  Medical  News,  February  i,  1890,  p.  99. 
■•*  Diet,  des  Sci.  Med.  (1819),  t.  xxxiv.,  p.  529. 


MAMM/IL    ERRATICS.  53 

mammje,  situated  below  and  internal  to  the  normal  ones  ;  and  between  these 
a  rudimentary  median  one,  five  inches  above  the  umbilicus. 

Max  Bartels  -^  alludes  to  an  instance  of  similar  malformation  in  a 
man. 

In  another  case^"'  an  exceedingly  beautiful  lady,  the  mother  of  five  well- 
formed  children,  had  a  small  rudimentary  median  mamma  rather  below  the 
level  of  the  normal  glands. 

Median  mammae  are  very  rare  in  the  animal  world  ;  but  in- 
stances occur  in  the  Virginian  Opossum  {Didelphys  virginiand). 
and  in  a  few  other  marsupials. 

From  the  foregoing  remarks  it  will  be  gathered  that  I  regard 
the  so-called  inamm(2  erratic<B  as  due  to  reversion  to  ancestral 
arrangements  much  more  ancient  than  those  reproduced  in 
ordinary  cases  of  polymastia.  There  is  no  evidence  whatever 
that  such  structures  can  arise  just  anywhere,  as  "  sports,"  from 
ordinary  sebaceous  follicles  ;  on  the  contrary,  I  have  shown  that 
they  only  arise  in  positions  corresponding  with  those  occupied 
normally  by  the  glands  of  polymastic  animals.  My  investiga- 
tions prove  that  highly  specialised  structures  like  the  mammary 
gland,  with  its  nipple  and  appendages,  never  develop  suddenly 
in  any  human  being,  except  in  response  to  ancestral  hereditary 
influence.  Were  it  otherwise,  human  beings  would  have  even 
more  mammae  than  Diana  of  Ephesus.  We  know  that  super- 
numerary teeth,  hke  supernumerary  mammae,  are  occasionally 
met  with  in  mankind.  But  these  redundant  teeth  do  not  occur 
just  anywhere  on  the  general  cutaneous  surface,  but  only  in 
certain  regions  of  the  mouth,  &c.,  hereditarily  predisposed  to 
produce  them.  Supernumerary  mammae  are  frequently  found 
on  the  general  cutaneous  surface  of  the  front  of  the  trunk,  but 
teeth  never.  What  is  the  reason  of  this  ?  The  answer  is,  that 
our  remote  ancestors  were  accustomed  to  have  mammae  de- 
veloped there,  but  not  teeth.  It  will  be  advanced  as  an  objec- 
tion to  this  reasoning   that  supernumerary  mammce  and  teeth 


-'  Reichert  and  Du  Bois  Reymond,  Arch,  fur  Aiiat.,  &c.,  1S72,  s.  306. 
"  Percy,   "  Mem.   sur  les  femmes  multimammae,"  Jour.  Je  Med.  de  Corvisart, 
An.  xiii. ,  t.  ix. ,  p.  381. 


54  POLYMASTIA. 

have  been  found  in  the  ivalls  of  ovarian  dermoid  cysts?^  I 
willingly  answer  this  objection,  as  it  will  afford  me  an  oppor- 
tunity of  refuting-  the  erroneous  interpretation  that  has  lately 
sprung  up  as  to  the  origin  of  these  remarkable  anomalies. 

The  current  view,  that  ascribes  the  origin  of  most  ovarian 
dermoid  cysts  to  sequestration  of  a  portion  of  the  cutaneous 
matrix,  at  an  early  stage  of  development,  enables  us  to  under- 
stand the  presence  of  hairs,  sebaceous  follicles,  sweat  glands, 
and  other  normal  dermal  structures  in  the  walls  of  such  cysts. 
Since  it  may  very  well  happen,  during  the  process  of  sequestra- 
tion, that  portions  of  the  matrix  of  adjacent  structures  may  also 
be  involved,  we  can  understand  on  this  hypothesis  how  it  is  that 
connective  and  fatty  tissues  may  be  found  in  connection  with 
such  cysts,  and  even  pieces  of  bone  and  cartilage. 

But  when  in  the  walls  of  congenital  ovarian  cysts  we  find 
highly  specialised  structures,  like  mammse  and  teeth,  which  are 
never  produced  in  the  normal  ontogeny  by  any  portion  of  skin 
likely  to  be  thus  sequestrated,  this  hypothesis  is,  I  maintain,  no 
longer  tenable.  In  these  cases,  I  believe,  we  have  to  do  with 
very  imperfect  parasitic  foetuses  per  inchisionem,  in  which  only 
the  mammae  or  teeth  of  the  parasite  have  survived."^  Many 
examples-^  of  this  kind  of  monstrosity  have  been  recorded,  in 
which  only  a  single  part  or  organ  of  the  parasite  has  developed  ; 
in  a  case  lately  published  by  KtimmeP"  there  was  only  a  rudi- 
mentary eye.  The  cases  of  cows  with  udders  on  the  back  and 
supernumerary  extremities  also  belong  to  this  category .^^ 


^Corradi,  A.,  Dell  Ostetrica  in  Italia,  Bologna,  1S74,  p.  1459;  Haffter,  E., 
Arch.  f.  Heilk.  1875,  s.  56  ;  Arch.  J.  path.  Anat.  (Velitz),  Bd.  cvii.,  s.  505  ;  Trans. 
Path.  Soc.  Loud.  (Sutton  and  Shattock),  vol.  xxxiv.,  pp.  437,  442. 

-'  It  is  no  objection  to  this  explanation  that  several  hundred  teeth  have  been  found 
in  a  single  cyst ;  because  under  such  abnormal  conditions  the  dental  germs  may 
multiply  almost  indefinitely  by  gemmation,  as  has  been  often  observed  in  dentigerous 
cysts  of  the  jaws. 

■^  Lannelongue,  Traiti  des  Kystes  Conghiitaux,  1886,  pp.  236-256.  I  have 
lately  seen  an  account  of  a  congenital  cyst  in  the  vicinity  of  the  orbit,  from  the  wall 
of  which  a  tooth  had  developed. 

■^  Arch.  f.  path.  Anat.,  Bd.  cxviii.,  Heft  I. 

^"  Bugnion  has  recently  described,  in  the  Revue  MM.  de  la  Suisse  Homande {lS8g, 
p.  334),  the  case  of  a  woman  with  a  parasitic  monstrosity,  consisting  of  pelvis  and 
lower  extremities,  which  was  attached  by  its  rudimentary  pelvis  to  her  pubic  region. 


SUPERNUMERARY    MAMMARY    STRUCTURES.  55 

§     II  I. The  General  Pathology  of  Supernumerary  Mammary  Structures. 

Mammary  anomalies  per  excessum  were  formerly  regarded 
as  great  rarities,  because  the  old  observers  noticed  only  very 
marked  examples,  to  which  their  attention  was  usually  drawn 
by  the  escape  of  milk  from  the  tumour.  Hence  most  of  their 
cases  were  in  women — pregnant  or  recently  confined. 

According  to  Bruce,^^  of  315  individuals  of  both  sexes,  taken 
indiscriminately,  ^6  per  cent,  presented  the  malformation;  of 
207  males,  it  was  present  in  9'i  per  cent.  ;  and  of  104  females, 
in  4-8  per  cent.  It  is  therefore  nearly  twice  as  frequent  in 
males  as  in  females.  Herein  it  resembles  most  other  congenital 
malformations,  which,  as  I  have  elsewhere  shown,^^  are  much 
commoner  in  the  male  than  in  the  female  sex.  In  this  connec- 
tion it  is  interesting  to  recall  the  observations  of  Darwin,^^  as 
to  the  great  proneness  of  secondary  sexual  characters  to  vary, 
especially  in  males. 

Supernumerary  mammary  structures  very  rarely  attain  the 
structural  and  functional  completeness  of  the  normal  glands  ; 
as  in  the  case  of  a  woman  described  by  Tarnier,^''  who  had  an 
extra  pair  of  abdominal  mammae,  which  equalled  the  normal 
ones  in  every  respect.  It  is  usual  to  find  the  supernumerary 
organ  represented  only  by  a  nipple — with  or  without  its  areola. 
In  other  instances  there  is  neither  nipple  nor  areola,  but  simply 
a  subcutaneous  mass  of  glandular  tissue,  which  may  commu- 
nicate with  the  surface  of  the  body  by  one  or  several  pores,  or 
be  altogether  cut  off  from  it.  Between  these  varying  structural 
grades  all  kinds  of  intermediate  conditions  are  met  with. 

In  its  least  degree,  the  malformation  per  excessum  is  repre- 
sented by  the  bifid  nipple. 


In  each  groin  she  had  a  nipple-Hke  process,  surrounded  by  a  pigmented  area,  which 
represented  the  mammse  of  the  parasite.  The  woman  herself  was  otherwise  well 
formed. 

'^'^  Journal  of  Anatomy,  vol.  xiii.,  p.  423. 

•'-  "The  Influence  of  Sex  in  Disease,"  Churchill  (1882),  p.  4. 

■"  "  Descent  of  Man  "  (1879),  p.  223,  et  seq. 

^'  Traiti  de  Part  des  Accouch.,  par  Cazeaux,  8me  ed.  (1S70),  p.  86. 


56  POLYMASTIA. 

DuvaP  says,  "  I  have  seen  a  young  woman,  25  years  old,  who  had  the 
nipple  of  each  breast  divided  nearly  to  its  base  into  two  equal  parts.  She 
said  her  nipples  had  been  thus  from  birth.  The  deformity  did  not  interfere 
with  lactation." 

Slight  exaggeration    here   leads    to   the    formation    of  two 

nipples  on  one  areola  (intra-areolar  polythelia),   as  in  a  case 

described  and  figured  by  Tiedemann.^® 

In  this  case  the  drawing  was  made  from  the  body  of  a  girl  in  the  dissect- 
ing room,  on  each  of  whose  otherwise  well-formed  breasts  two  nipples  were 
found  within  one  areola — one  nipple  perpendicularly  below  the  other. 

In  other  cases  one  or  more  supernumerary  nipples,  each  with 
its  own  areola,  have  been  met  with,  in  various  positions,  on  a 
single  breast  (intra-mammary  polythelia^^). 

Percy  and  Laurent'*^  in  their  clever  essay,  have  related  a  remarkable 
instance  of  this  kind.  The  patient  was  a  woman  who  had  two  large  pectoral 
mammae  in  the  normal  position,  of  which  the  left  was  furnished  with  five 
nipples,  each  with  its  own  areola,  and  the  right  with  two  nipples,  also  with 
distinct  areola;. 

PrackeP  saw  a  Scotch  woman  with  three  nipples  on  each  breast, 
arranged  so  that  they  corresponded  to  the  angles  of  an  equilateral  triangle, 
the  two  additional  ones  being  below  the  normal  nipple.  Each  of  them  gave 
milk.     The  woman  had  given  birth  to  twins  several  times. 

De  Smety^'^  and  Tarnier"  have  each  related  a  case  of  intra-mammary 
polythelia  in  women  whose  mothers  had  identical  malformations. 

A  most  remarkable  instance  of  the  inheritance  of  redundant 
nipples  has  been  recorded  by  Blanchard.^^ 

A  man,  the  father  of  thirteen  children — seven  males  and  six  females — 
had  a  supernumerary  nipple  with  a  rudimentary  areola  on  each  breast,  a 
few  cm.  below  each  normal  nipple.  All  his  seven  sons  had  the  like  deformity, 
but  none  of  his  daughters.  The  youngest  of  the  sons  became  the  father  of 
five  children — four  boys  and  one  girl.  All  the  boys  had  supernumerary 
nipples  like  their  father,  grandfather,  and  six  uncles. 


•"  Duval,  Du  Manielon  et  de  son  aureole,  Paris  (1861),  p.  90. 

**  Tiedeman  and  Trevirariiis,  Unlersiicliung  iiber  die  Nat.  der  A/tiisc/i,  &c. 
(1831),  Bd.  v.,  s.  no,  taf.  i.,  fig.  3. 

^  Uuval,  Op.  cit.,  p.  83  «/.  seq.  ;  Engestrom,  O.,  Jn/i.  de  Gynec,  t.  31,  p.  282; 
Chowne,  Lancet,  vol.  ii.,  1842,  p.  465  ;  Puech,  Of>.  cit.,  p.  84. 

^  Diet,  des  Sci.  A/^d  (iSig),  t.  34,  p.  525. 

*'  MiscelL  Curios.,  <^c.,  Dec.  ii.  Ann.  v.,  App.  Ohs.  67,  p.  40. 

">  Gaz.  Med.  de  Paris  {1S87),  p.  317. 

"  Cazeaux,  Traile  de  Part  des  Accouch.,  8'  ed.  (1870),  p.  86. 

'-'  Bull,  de  la  Soc.  d'Anthropologie,  t.  ix.  (1886),  p.  485. 


SUPERNUMERARY    MAMMARY    STRUCTURES. 


57 


These  anomalies  arise  from  excessive  growth  of  the  rudi- 
ment of  the  gland  and  nipple,  after  the  developmental  process 
has  made  a  certain  amount  of  progress  ;  consequently  the  causes 
which  determine  them  must  be  referred  to  a  much  later  stage 
of  embryonic  development  than  those  which  determine  atavistic 
supernumerary  mammae.  That  is  to  say,  the  causes  of  these 
malformations  are  of  the  same  nature  as  those  which  originate 
discontinuous  grozvth  in  general. 

From  such  conditions,  which  are  relatively  rare,  I  will  now 
pass  to  those  much  commoner  ones,  in  which  the  super- 
numerary mammary  structures  are  quite  independent  of  the 
normal   breasts. 


Fig.   12.— a  pair  of  supernumerary  mammary  structures  in  a  boy. 

The  above  figure  represents  a  boy,  ii  years  old,  with  a  pair  of  super- 
numerary nipples,  etc.,  two  inches  below  and  slightly  internal  to  the  normal 
ones,  which  they  nearly  equalled  in  every  respect.  The  patient  was  under 
treatment  for  tubercular  lymphadenitis  of  the  neck  of  three  years'  duration. 
The  figure  is  from  a  photograph,  for  which  I  am  indebted  to  Mr.  Jesset. 

The  number  of  these  supernumerary  parts  may  vary  from 
one  to  eight,  but  more  than  two  are  very  exceptional.  Of 
Leichtenstern  and  Bruce's  i66  cases,  in  112,  or  two-thirds, 
there  was  only  a  single  extra  structure.  Such  single  re- 
dundant mammary  structures  are  almost  invariably  situated 
a    little    below    and    internal    to    the    corresponding    normal 


5S 


POLYMASTIA. 


mammae,  in  the  position  of  the  fifth  pair  of  my  diagram  (fig.  lO), 
and  in  females  they  are  much  more  frequently  seen  on  the  left 
than  on  the  right  side.*^  I  have  not  found  the  same  dispropor- 
tion in  males;  for,  on  separating  the  sexes  in  Bruce's  list:  of 
42  males,  the  deformity  occurred  on  the  left  side  in  22,  and  on 
the  right  in  20. 

A  small  proportion  of  these  single  extra  mammary  struc- 
tures are  met  with  lower  down  than  the  above,  in  a  position 
corresponding  to  that  occupied  by  the  sixth  pair  of  my  diagram. 
Both  Leichtenstern  and  Bruce  have  recorded  several  such  cases. 


Fig  13. — A   pair    of    supernumerary   mammary  structures   in  a    young   woman 
(Leichtenstern). 

In  the  great  majority  of  the  remaining  cases  there  was 
present  a  pair  of  supernumerary  mammary  structures,  situated 
a  little  below  and  internal  to  the  normal  glands,  in  the  position 
of  the  fifth  pair  of  my  diagram  (fig.  10}.     Typical  instances  of 


'■'  Of  loi  single  cases  in  Leichtenstern  and  Bruce's  lists,  64  were  on  the  left  side, 
and  only  37  on  the  right. 


SUPERNUMERARY    MAMMARY    STRUCTURES.  59 

this  kind  in  males  have  been  recorded  by  Max  Bartels,*^  Handy- 
side,'*'^  &c.  ;  and  in  females  by  Leichtenstern/^  Whitford/^ 
Chatard,'''  and  others. 

In  Leichtenstern's  case  (fig.  13)  the  patient  was  a  healthy  young  woman 
with  a  redundant  pair  of  small,  erectile,  symmetrical  nipples,  each  sur- 
rounded by  a  pigmented  areola,  situated  just  below  and  internal  to  the 
normal  mammee. 

In  more  than  three-fourths  of  all  cases,  supernumerary 
mammary  structures  have  been  found  in  this  situation,  on  one 
or  both  sides  ;  and  it  is  significant  that  elsewhere  such  con- 
ditions are  most  exceptional.  We  may  conclude  from  this, 
that  our  progenitors  had  a  redundant  pair  of  thoracic  mammse 
here,  long  after  they  had  lost  all  their  other  supernumerary 
glands.  In  some  Lemurs  a  similarly  placed  second  pair  of 
pectoral  mamms  is  still  of  normal  occurrence. 

In  a  certain  number  of  cases  a  supernumerary  pair  of 
mammae  has  been  found  below  and  internal  to  the  above,  in 
the  position  of  the  sixth  pair  of  my  diagram  (fig.  10).  Typical 
instances  of  this  kind  in  men  have  been  recorded  by  Leichten- 
stern^'^  and   Hamy,^^  and  in  women  by  Rapin,^^  De  Sinety,^^  &c. 

Abdominal  mammae  in  human  beings  are  very  rare.  I 
know  only  of  the  following  cases  : — 

The  most  remarkable  is  Tarnier's^'* — 

He  says,  "  I  have  myself  seen  a  woman  with  four  breasts,  who  died  in 
the  Maternity  Hospital.  Two  breasts  of  the  usual  size  occupied  the  normal 
position  ;  while  two  others,  as  fully  developed,  were  situated  on  the  upper 
and  lateral  parts  of  the  abdomen,  nearly  in  the  vertical  line  with  the  thoracic 
ones.  At  the  necropsy  I  found  abundance  of  glandular  tissue  in  all  four 
breasts,  which  also  contained  milk." 


^^  Reichert  and  Du  Bois  Reymond,  Arch.f.  Anat.  {1872),  s.  304. 

^''  yozirnal  of  Anatomy  (1872),  p.  56. 

'"'  Arch.  f.  path.  Anat.,  Bd.  Ixxiii.,  s.  252,  No.  87,  taf.  iv.,  fig.  4. 

■•^  Chicago  Aled.  J  our.  and  Examiner  {1%?,^),  p.  528. 

*®  jfotcrnal  de  Aled.  de  Bordeaux,  Sept.,  1861. 

'>"  Op.  cit.,  s.  251  (No.  85),  taf.  iv.,  fig.  2. 

^'  Bull,  de  la  Soc.  d^Anthropologie,  t.  viii.  (18S5),  p.  229. 

■'-  Rev.  Aled.  de  la  Suisse  Romande  (1882),  p.  472. 

■■^   Gaz.  Med.  de  Paris  (1887),  p.  317. 

^'  Cazeaux,  Op.  cit.y  p.  86. 


6o  POLYMASTIA. 

Bartholin"  has  seen  a  woman  with  a  pair  of  supernumerary  mammas  in 
the  same  situations,  each  the  size  of  the  normal  male  breast. 

Bruce'^^  has  described  and  figured  a  redundant  nipple  in  this  situation  in 
a  man,  and  says  he  has  seen  several  other  instances  of  the  kind. 

In  Mortillet's  and  Alexander's  cases,  already  alluded  to,  a  pair  of  super- 
numerary mammary  structures  were  present  in  this  situation,  nearly  as 
perfect  as  the  normal  ones. 

A  case  recorded  by  McGiUicuddy"  differs  from  all  the  foregoing,  in 
that  the  supernumerary  structures  were  much  lower  down.  The  anomaly 
occurred  in  a  man,  aged  35,  who  had  a  pair  of  rudimentary  mammas  at  about 
the  level  of  the  umbilicus,  three  to  four  inches  from  it.  These  yielded  a 
milk-like  fluid,  which  contained  numerous  colostrum  corpuscles. 

It  seldom  happens  (12  out  of  166  cases)  that  supernumerary 
mammary  structures  are  met  with  above  the  normal  glands. 
When  this  is  the  case,  it  is  interesting  to  note  that  the  re- 
dundant structures  are  always  found  external  to  the  normal 
ones,  as  in  polymastic  animals.  Cases  of  this  kind  will  be  cited 
in  the  section  on  axillary  mammae. 

Probably  all  races  of  men  are  subject  to  these  malforma- 
tions ;  instances  have  been  met  with  in  nearly  all  European 
nations,  and,  in  addition,  in  a  Mongol,  West  Indian,  Malayan, 
in  a  Mulatto  from  the  United  States,  and  in  a  Mulattress  from 
the  Cape,  a  Moorish  woman,  and  a  Negress. 

With  regard  to  their  occurrence  in  animals,  Owen  says^^ : — 
"  In  the  Orang-utan  {Pithecus  satyrus),  I  have  observed  an 
accessory  nipple  on  the  left  side,  below  the  normal  one,  and  of 
smaller  size." 

Our  domestic  cows  have  normally  four  well-formed,  and 
often  two  rudimentary  teats.  I  have  several  times  seen  the 
latter  well  developed,  and  they  occasionally  yield  milk.  The 
supernumerary  teats  are  always  placed  behind  the  normal  ones. 
Of  the  two  normal  pairs  the  anterior  one  is  generally  obviously 
longer  and  larger  than  the  other.     I  have  seen  a  cow  with  all 


Epist.  Med.,  cent,  iv.,  No.  38,  p.  218. 
'Journal  of  Anatomy,  vol.  xiii.  (1879),  p.  446. 
N.  Y.  Med.  Kec,  Oct.   10,  1891,  p.  447. 
"  Comp.  j4nai.,  vol.  iii. ,  p.  780. 


SUPERNUMERARY    MAMMARY    STRUCTURES.  6 1 

these  three  pairs  of  teats  well  developed,  and  with,  in  addition, 
a  fourth  rudimentary  pair  behind  the  last  of  the  three  well- 
developed  ones.  I  have  also  seen  a  cow  with  five  teats,  an 
anterior  pair  corresponding  to  the  normal  one,  a  posterior  pair 
corresponding  to  the  ordinary  supernumerary  one,  and  between 
these  a  single  long,  thin,  flabby  teat,  corresponding  to  the  left 
one  of  the  normal  posterior  pair,  its  fellow  having  completely 
aborted.  Variations  in  the  number  and  degree  of  development 
of  the  teats  of  cows  are  of  common  occurrence. 

In  sheep,  which  are  also  prone  to  this  anomaly,  the  addi- 
tional teats  are,  according  to  Sanson,-^^  always  found  in  front 
of  the  normal  ones.  Daubenton^'^  has  described  a  goat  with 
double  teats  on  each  udder,  and  instances  of  redundant  mam- 
mary structures  have  been  met  with  in  various  monkeys,  cows, 
and  other  animals.  It  may  be  inferred,  with  tolerable  certainty, 
that  all  animals  having  normally  but  a  few  mammae  are  liable 
occasionally  to  have  additional  ones  developed. 

The  question  has  been  raised  whether  polymastic  women 
are  more  liable  than  others  to  beget  more  than  a  single  child  at 
a  birth.  Of  seventy  polymastic  women  in  Leichtenstern's  list, 
three  had  given  birth  to  twins,  or  4'3  per  cent.  This  proportion 
is  much  above  the  average,  which  for  Great  Britain  is  only 
about  I  per  cent. 

In  this  connection,  Marie's''^  recently  recorded  case,  in  which  a  marked 
hereditary  anomaly  of  this  kind  was  associated  with  frequent  twining  and 
very  large  families,  is  of  interest. 

The  patient  was  a  young  girl  with  a  supernumerary  nipple  below  her 
left  breast,  in  whose  family  this  anomaly  had  been  traced  for  four  genera- 
tions. In  all  of  those  affected  but  two,  the  supernumerary  nipple  was,  as  in 
the  patient.  Of  her  eleven  brothers  and  sisters  four  were  twins  ;  and  of  her 
father's  fifteen  brothers  and  sisters  six  were  twins  ;  all  these  six  had  super- 
numerary nipples,  while  in  none  of  the  nine  remaining  children  did  the 
anomaly  exist.  Marie  points  out  that  the  faculty  of  bearing  twins  in  women 
is  not  less  certain  than  the  faculty  of  begetting  twins  that  is  observed  in 
men.     The  father  of  the  girl  in  this  case  was  a  twin,  he  begat  two  pairs  of 


Bull,  de  la  Soc.  cT Anthropologic,  t.  ix.  (1886),  p.  511. 

Fourcroy's  "Med.  eclairee,"  t.  v.,  tab.  12. 

Btill.  de  la  Soc.  Med.  des  Hop.,  t.  x.  (1893),  P-  457- 


62  POLYMASTIA. 

twins,  and  one  of  his  brothers,  also  a  twin,  became  the  father  of  at  least 
one  pair. 

In  polymastia  the  normal  pectoral  pair  of  mammae  are  in- 
variably present  in  their  proper  position,  and  well  developed. 

It  is  very  unusual  to  find  these  anomalies  associated  with 
other'congenital  malformations,  as  in  cases  of  amazia. 

Bryant,'^'  however,  has  seen  a  girl,  aged  6,  with  a  supernumerary  nipple 
on  the  left  side,  below  the  normal  one,  in  whom  the  vagina  was  absent,  and 
she  had  a  clitoris  as  large  as  a  boy's  penis. 

Voltaire''^  also  relates  having  seen  at  a  fair  a  woman  with  a  pair  of 
redundant  mammas,  "  qui  portait  de  plus  au  croupion  une  sorte  d'excrois- 
sance  converte  de  peau  et  de  poils,  la  quelle  ressemblait  a  une  queue  de 
vache." 

It  is  alleged  that  in  the  beautiful  Anne  Boleyn,  polymastism  was  asso- 
ciated with  polydactylism. 

Supernumerary  mammary  structures  are  often  hereditary 
as  in  the  previously  mentioned  cases  of  Blanchard  and  Marie. 
In  seven  out  of  ninety-two  cases  {y6  per  cent.)  collected  by 
Leichtenstern  there  was  history  of  similar  malformation  in  near 
relatives. 

In  Petrequin's  case,^^  the  father,  his  three  sons  and  two  daughters,  each 
had  a  single  supernumerary  pectoral  mamma. 

Handyside^"  has  seen  two  brothers,  each  with  a  supernumerary  pair  of 
pectoral  nipples  below  the  normal  ones. 

In  a  case  related  by  Edwards,*"^  a  man  had  a  single  additional  nipple 
with  areola  below  the  right  normal  one,  and  his  sister  had  a  similar  deformity 
of  the  left  side.  Edwards  had  the  opportunity  of  examining  both  persons. 
Bathurst  Woodman  '^^  has  recorded  the  case  of  a  woman  with  a  super- 
numerary nipple  below  the  left  breast,  whose  daughter  had  the  like 
deformity.  Roberts'  case  has  been  already  mentioned.  Other  instances 
of  hereditary  polymastism  by  Bartholinus,  Tiedemann,  and  Scalzi  have  also 
been  previously  referred  to. 

Anomalies  of  this  kind  are  often  overlooked  for  the  want 


'«  "  Diseases  of  the  Breast"  (1887),  p.  9. 

•^  Did.  Philosophiiinc,  art.  "  Monstres." 

"•  Gaz.  Mcdicale,  av.  1837,  p.  195. 

^''  Journal  of  Aiiato?ny,  vol.  vii.  (1872),  p.  56. 

««  Phil.  Med.  Neivs,  1886,  p.  264. 

''"  Obstel.  Soc.  Trans.  (London),  vol.  ix.  (1867),  p.  50. 


AXILLARY    MAMMARY    STRUCTURES.  63 

of  knowing  what  to  expect.  Those  who  know  luhere  to  look  and 
what  to  look  for  are  not  Hkely  to  have  much  difficulty  in  making 
a  diagnosis.  In  minor  degrees  of  this  deformity,  instead  of 
a  redundant  nipple,  only  a  depression  may  be  found  {athelia). 
Hairs  are  never  seen  on  normal  nipples;  but  the  supernumerary 
ones  occasionally  have  them.^^  In  many  instances  supernu- 
merary mammary  structures  have  been  mistaken  for  moles, 
naevi,  lipomata,  and  cold  abscesses.  Morbid  growths  in  con- 
nection with  the  nipple  sometimes  simulate  supernumerary 
malformations.  I  lately  saw  a  middle-aged  married  woman 
with  a  small  molluscum  Jibrosum  near  the  nipple,  which  it 
closely  resembled.  I  have  already  alluded  to  the  resemblance 
between  some  cases  of  supernumerary  mammae  and  the  con- 
dition resulting  from  chronic  fistula,  in  connection  with  seba- 
ceous and  dermoid  cysts  that  have  undergone  suppuration. 
Very  little  help  is  to  be  got  from  the  metropolitan  museums 
in  this  matter ;  altogether  they  contain  but  a  single  specimen  ! 
This  vara  avis  is  to  be  found  in  the  museum  of  the  London 
Hospital — a  single  supernumerary  nipple  from  a  man.  As 
a  rule,  supernumerary  mammary  structures,  being  small  and 
rudimentary,  hardly  attract  the  notice  even  of  those  who  bear 
them.  Sometimes,  however,  especially  in  women  during  lacta- 
tion, the  overflow  of  milk  from  them  causes  considerable 
annoyance. 

There  can  be  no  doubt  as  to  the  propriety  of  excising  such 
redundant  parts  for  those  who  desire  to  be  relieved  of  the 
deformity,  and  the  procedure  is  free  from  danger. 

§    IV. Axillary  Supernumerary  Mammary  Structures. 

The  subject  of  supernumerary  mammary  structures  in  the 
axilla  and  its  vicinity  is  of  such  importance,  that  I  propose  to  • 
devote  a  special  section  to  its  consideration. 

Two  varieties  of  this  condition  may  be  met  with  ;  a  com- 
moner one  due  to  sequestration,  and  a  rarer  one  of  atavistic 
origin. 

•'  Biuce,  Op.  cit. 


64 


POLYMASTIA. 


Several  anatomists  have  recognised  the  fact,  that  in  females 
a  process  of  the  mammary  gland  is  not  infrequently  prolonged 
round  the  border  of  the  pecto'alis  major  muscle  right  into  the 
axilla.  According  to  Hennig  ''^  the  fully  developed  female 
mamma  has  normally  a  tricuspid  form,  two  of  the  cusps  pro- 
jecting towards  the  axilla — an  upper  and  a  lower  one — and  the 
other  towards  the  sternum.  It  is  the  upper  of  these  two 
axillary  mammary  extensions  that  so  often  extends  right  into 


Fig.   14. — A  pair  of  enlarged  milk-secreting  axillary  sequestrations  in  a  puerperal 
woman  {McGillkmidy). 


the  axilla.  Though  commonest  in  the  axillary  region,  similar 
glandular  offshoots  project  from  other  parts  of  the  mamma. 
The  connection  of  these  outlying  processes  with  the  corpus 
vianimcB  is  often  reduced  to  a  narrow  pedicle;  and  not  infre- 
quently by  its  rupture  they  become  completely  sequestrated. 

I    have   found    on   record   numerous    instances  of  so-called 
axillary  mammae ;  but  when  one  comes  to  examine  these  cases 


"  Arch.f.  Gytu,  Bd.  ii.,  1871,  s.  331. 


AXILLARY    MAMMARY    STRUCTURES.  65 

critically  only  a  very  few  of  them  can  be  definitely  accepted  as 
such  ;  most  of  them  are  of  the  nature  of  axillary  mammary 
extensions  or  sequestrations.  I  have  not  met  with  a  single 
instance  of  the  kind  in  a  male.  Subjoined  ar-e  abstracts  of 
some  typical  cases. 

IP — The  patient  (fig.  14,)  was  a  well  developed,  healthy,  married  woman, 
aged  24,  who  during  her  second  pregnancy  first  noticed  a  swelling  in  each 
axilla.  Soon  after  her  confinement  these  increased  in  size  ;  and  milk 
escaped  through  minute  pores  in  the  overlying  skin,  causing  her  much 
discomfort  through  keeping  her  clothes  constantly  wet. 

n.*^^ — Puech  has  reported  the  case  of  a  woman,  aged  19,  who  the  day 
after  her  first  confinement,  noticed  a  sweUing — the  size  of  half  a  hen's  egg- 
in  her  left  axilla,  immediately  beneath  its  anterior  border.  The  superjacent 
skin  was  not  adherent,  nor  pigmented,  nor  otherwise  discoloured  ;  and  no 
trace  of  a  nipple  existed.  On  pressing  the  swelling  a  few  drops  of  milk 
oozed  from  the  skin.  The  corresponding  breast  was  full  of  milk,  which 
freely  issued  from  its  healthy  nipple.  The  tumour  felt  as  though  com- 
posed of  mammary  glandular  tissue  ;  and  a  distinct  cord  could  be  traced 
from  its  inner  aspect  to  the  left  breast.  On  exploring  the  right  axilla  a 
similar  swelling  was  found.  It  was  slightly  smaller  than  its  fellow,  but  in 
other  respects  precisely  similar.  There  was  no  nipple  and  no  visible 
external  orifice,  but  milk  exuded  from  the  skin  on  pressure,  and  there  was 
a  cord  running  to  the  right  breast.  Shortly  afterwards  the  patient  went 
out  as  a  wet  nurse.  The  breasts  were  full  of  milk  but  none  issued  from  the 
skin  over  the  swellings,  which  soon  diminished  in  size  ;  and  in  the  course 
of  a  fortnight  they  had  almost  disappeared.  The  axillary  swellings  in  this 
case  were  evidently  nothing  but  pedunculated  axillary  mammary  extensions. 

in.'-'' — Bue  attended  a  woman  in  her  third  confinement,  which  occurred 
at  term.  Two  days  later  a  swelling  developed  in  the  anterior  part  of  each 
axilla,  especially  on  the  right  side.  The  normal  breasts  were  full  of  milk. 
The  swelling  on  the  right  side  was  situated  on  the  border  of  the  pectoralis 
major  and  on  the  thoracic  wall  in  the  adjacent  part  of  the  axilla.  It 
measured  25-  inches  in  diameter  and  over  6  in  circumference,  and  was 
separated  by  a  groove  from  the  normal  gland.  When  the  child  was  put  to 
the  right  breast  a  distinct  diminution  in  the  size  of  the  axillary  swelling  was 
observed.  Afterwards  it  again  enlarged.  There  was  no  trace  of  any  nipple 
The  left  axillary  swelling  lay  in  the  same  position  as  the  right,  but  was 
much  smaller.  On  the  day  after  its  appearance  it  vanished.  Its  fellow  on 
the  right  side  remained  stationary  all  the  time  that  the  patient  suckled. 

IV. — Champneys  ''^  has  related  the  three  following  striking 

''  JV.   Y.  Med.  Record,  Oct.  10,  1891,  p.  447.     McGillicuddy's  case. 

'*  Arch,  de  Toe.  et  de  Gyn.,  May,  1S92. 

"  3zd., ]nne,  1893. 

""  A/ed.  Chir.  Traits.,  vol.  l.xix.,  1886,  p.  429. 


66  POLYMASTIA. 

examples  of  this  condition  in  lying-in  women.     In  all  of  these 
cases,  as  in  Bue's,  no  secretion  escaped  externally. 

(i)  On  the  third  day  after  admission  a  mammary  extension,  two  inches 
broad,  was  noticed  in  each  axilla,  to  the  apex  of  which  it  reached.  These 
extensions  joined  the  outer  border  of  the  mammary  gland  at  a  tangent  ; 
they  felt  nodular,  and  in  all  respects  like  the  mamma  itself. 

(2)  On  the  sixth  day  after  admission  a  mammary  extension  was  felt  on  the 
inner  wall  of  each  axilla.  These  extensions  were  obviously  connected  with 
the  breasts,  and  they  felt  just  like  them. 

(3)  On  the  second  day  after  admission  there  was  noticed  a  nodular  pro- 
longation from  the  outer  side  of  each  mamma  along  the  inner  wall  of  the 
axilla,  nearly  to  the  apex. 

V. — Charcot  and  Legendre''''  have  recorded  two  instances  in 
which  supernumerary  nipples — in  one  case  with  and  in  the  other 
without  an  areola — were  met  with  in  connection  with  axillary 
mammary  extensions. 

In  each  there  was  but  a  smgle  supernumerary  nipple,  which  was  situated 
just  above  and  external  to  the  normal  one — in  one  case  on  the  left  side  and 
in  the  other  on  the  right.  In  both  these  cases  the  connection  between  the 
supernumerary  nipples  and  the  mammary  extensions  was  verified  hy  post- 
vwrtevi  examination. 

VI. — In  Notta's'**  case  there  was  a  tumour  the  size  of  a  walnut  over  the 
middle  of  the  left  anterior  axillary  border,  which  was  connected  with  the 
breast  by  a  narrow  pedicle.  On  pressure  milk  escaped  through  a  single 
small  pore  in  the  overlying  skm.  There  was  no  sign  of  nipple  or  areola, 
and  the  other  axilla  was  normal.  The  patient  was  a  woman,  aged  26, 
who  was  suckling  her  fourth  child.  No  escape  of  milk  in  the  axilla  had 
taken  place  during  previous  lactations.  To  account  for  this  Notta  has  made 
the  feasible  suggestion,  that  on  these  occasions  the  secretion  from  the 
tumour  was  carried  off  by  the  normal  nipple  through  the  pedicle,  which 
subsequently,  for  some  reason  or  other,  became  occluded  ;  when  the  accu- 
mulating secretion  made  its  exit  by  the  axilla.  In  order  to  determine  the 
precise  nature  of  this  condition  Notta  dissected  the  mammje  of  a  number  of 
women.  In  one,  aged  26,  who  died  in  child-bed,  he  found  an  axillary 
mammary  extension,  which  presented  as — "  Une  sorte  de  cordon  qui, 
suivant  le  bord  externe  du  grand  pectoral,  remontait  vers  le  milieu  du 
deuxi^me  espace  intercostal." 

VII. — Champneys^''  has  seen  two  similar  cases  in  lying-in  women.  In 
both  there  was  supernumerary  gland  substance  in  each  axilla,  which  dis- 

"  Gaz.  MM.de  Paris,  1859,  p.  773. 

"*  Arch,  de  Toe.  et  de  Gyn.,  1882,  p.  108. 

"^  0/>.  dl.,  pp.  430,  43  [. 


AXILLARY     MAMMARY    STRUCTURES.  67 

charged  externally  by  a  single  pore  at  the  middle  of  the  anterior  axillary 
borders.  In  another  of  Champneys'  cases,**"  a  lying-in  woman  had  a  supernu- 
merary mammary  swelling  in  each  axilla,  connected  with  the  normal  gland  by 
a  narrow  pedicle.  On  pressure  milk  escaped  from  each  of  them,  through  a 
small  pore  in  the  overlying  skm. 

VIII. — Precisely  similar  cases,  without  any  communication 
with  the  cutaneous  surface,  have  been  met  with  by  Polden,'" 
Godfrain,''*^  Maschat,^-"^  and  Auvard.^* 

Conditions  of  this  kind  may  easily  be  mistaken  for  enlarged 
axillary  glands,  tumours,  hypertrophied  cutaneous  sebaceous 
glands  ("axillary  lumps"  of  Champneys),  abscess,  &c. 

Numerous  examples  of  axillary  mammary  seguestrationsh^Me, 
from  time  to  time,  been  recorded.  In  what  follows  reference  is 
made  to  the  most  important  of  these. 

L — Meyer^''  has  reported  the  case  of  a  woman,  aged  27,  who  shortly  after 
her  third  confinement,  first  noticed  a  lobulated  tumour  in  her  left  axilla,  un- 
connected with  the  breast,  and  not  in  communication  with  the  cutaneous 
surface.  A  little  later,  above  and  external  to  the  left  breast,  she  noticed 
another  tumour.  As  the  patient  feared  she  had  cancer,  having  lost  a  relative 
from  this  disease,  the  axillary  tumour  was  dissected  out.  It  proved  to  be  a 
mammary  gland  tumour,  containing  milk,  and  having  no  connection  with  the 
breast;  this  was  verified  by  microscopical  examination.  The  other  tumour 
subsequently  disappeared  spontaneously. 

II. — Martin,'**'  Siebold,-''  Champion,^^  Harris,^^  Dixon,^"  and  Moore,^'  have 
each  of  them  seen  a  lying-in  woman  with  a  tumour  the  size  of  a  hen's  &gg  in 
both  axillae,  whence  milk  exuded  on  pressure  through  several  small  pores  in 
the  overlying  skin.  No  nipple  was  present  in  either  of  these  cases  ;  nor  is 
mention  made  of  any  connection  between  the  axillary  tumours  and  the 
normal  mammse. 


s"  op.  cit.,  p.  423. 

*'  Indian  Med.  Gaz.,  vol.  xxii.,  1887,    p.  241. 

*'  These  de  Paris,  1877,  p.  35.     "  Surl  es  inamelles  surnumeraires." 

^^  These  de  Paris,  1883,  No.  184.      "  Anomalies  de  la  mamelle." 

"  Arch,  de  Toe.  et  de  Gyn.,  t.  xv.,   188S,  p.  622. 

*^  N.  Y.  Med.  Record,  1886,  vol.  i.,  p.  455. 

*°  Annal.  d^Occtclist  et  de  Gyn.,  t.  i.,  liv.  8. 

8"  Med.  Ztg.  V.  e.   Vereinf.  Heilk,  in  Pr.,  1838,  No 

*^  Diet,  des  Sci.  Med.,  t.  xxx.,  p.  377. 

**  Med.  Times  and  Gaz.,  1861,  vol.  i.,  p.  397. 

*"  Lancet,  1843,  vol.  ii.,  p.  844. 

s'  Lancet,  1838,  p.  786, 


68  POLYMASTIA. 

III. — In  a  case  seen  by  Cameron,-'-  a  woman  aged  ;i^,  in  her  sixth 
lactation,  had  a  tumour  the  size  of  a  hen's  egg  in  the  left  axilla,  from  which 
milk  escaped  on  pressure  through  a  single  small  pore.  She  first  noticed  the 
swelling  after  having  over-exerted  herself  in  extinguishing  a  fire  when  she 
was  pregnant  with  her  sixth  child.  In  all  her  previous  confinements  she  was 
free  from  any  axillary  trouble.  It  seems  probable  here,  as  in  Notta's  case, 
that  the  tumour  was  formerly  connected  with  the  normal  gland  by  a  pedicle, 
which  carried  off  its  secretion  j!^^r  zn'as  natitrales. 

Cohn''^  has  recorded  a  precisely  similar  case,  also  on  the  left  side. 

IV. — Matthews  Duncan'"  has  published  an  account  of  a  woman,  aged  26, 
who,  in  the  ninth  month  of  her  pregnancy,  complained  of  constant  wetness 
in  the  right  axilla.  Four  days  after  her  confinement  a  tumour  the  size  of  a 
walnut  was  found  in  this  situation,  which,  on  pressure,  emitted  milk  through 
a  single  small  pore  in  the  overlying  skin.  The  tumour  had  no  obvious  con- 
nection with  the  normal  mamma. 

Turney,'-*'  Auvard,^**  and  Hare"''  have  met  with  precisely  similar  conditions 
in  women,  also  on  the  right  side. 

In  the  cases  of  Harris  and  Hare,  milk  cysts  formed  in  the  axilla. 

V. — Johnson''^  has  described  a  curious  condition,  in  which  there  formed 
in  the  right  axilla  of  a  woman,  during  her  third  pregnancy,  a  pear-shaped, 
pendulous,  lobulated  tumour,  like  the  male  scrotum.  Its  size  was  greatest 
just  before  accouchement  and  shortly  afterwards,  when  it  measured  nine 
inches  in  circumference.  On  squeezing  it  milk  exuded  through  several  small 
pores,  over  its  lower  part.  It  was  evidently  an  axillary  galactocele.  She 
had  also  a  small  tumour  in  the  left  axilla.  During  her  previous  pregnancies 
nothing  abnormal  had  been  noticed  in  either  axilla. 

VI. — Neve^^  has  reported  a  similar  case  : — 

The  patient  was  a  Kashmiri  woman,  aged  25,  who  came  under  his  notice, 
with  a  tumour  the  size  of  a  hen's  egg  in  her  left  axilla.  It  felt  lobulated,  and 
the  overlying  skin,  which  was  much  pitted,  was  adherent  to  it.  The  tumour 
formed  during  her  first  pregnancy  five  years  ago.  It  was  excised,  and  proved 
to  be  circumscribed,  and  unconnected  with  any  important  adjacent  structures. 
On  section,  after  removal,  it  consisted  of  congeries  of  convoluted  tubes,  the 
thickness  of  a  crow-quill,  which  contained  thick,  yellowish  substance,  re- 
sembling inspissated  milk.  It  was  evidently  an  old  axillary  galactocele, 
that  had  originated  from  an  axillary  mammary  sequestration. 


*■■'  Journal  of  Anatomy,  vol.  xiii.,  1879,  p.  149. 

"«  Berlin  klin.  Woch.,  1885,  S.  291. 

**  Obstetrical  Journal,  1873,  vol.  i.,  p.  516. 

95  Phil.  Med.  Ne7us,  1886,  p.  264. 

^  Arch,  de  Toe.  et  de  Cyii.,  1888,  p.  622. 

*'  Lancet,  i860,  vol.  ii. ,  j).  405. 

**  Boston  Med.  and  .'^ur^.  Journal,  1886,  vol.  ii.,  p.  547 

*"  Lancet,  1894,  vol.  i.,  p.  801, 


AXILLARY    MAMMARY    STRUCTURES. 


69 


We  can  now  proceed  to  study  the  various  much  rarer  forms  of 
atavistic  supernumerary  mammary  structures  met  with  in  the 
axilla  and  its  vicinity. 

First  of  all,  with  regard  to  those  found  in  the  vicinity  of  the 
axilla.  Several  cases  are  on  record  of  supernumerary  mammae 
occupying  a  position  corresponding  to  the  third  pair  of  my 
diagram  (fig.  10)  i.e.,  just  above  and  a  little  external  to  the  swell 
of  the  bosom.     Subjoined  are  abstracts  of  four  cases  of  this  kind. 


Fig.   15. — A  pair  of  supernumerary  mammse  above  the  normal  ones  {Shannon). 

(i)  In  Shannon's  case'""  the  patient  was  a  woman,  aged  34,  who  came 
under  observation  soon  after  her  sixth  confinement,  when  it  was  noticed 
that  she  had  a  pair  of  supernumerary  breasts  just  above  and  external  to  the 
normal  ones  (fig.  15).  Each  of  the  redundant  organs  was  the  size  of  a  large 
goose's  &%^.  Curiously  enough,  the  right  supernumerary  gland  was  furnished 
with  two  nipples,  and  the  left  with  a  single  one  ;  each  nipple  had  its  own 
well-developed  areola,  and  during  lactation  milk  flowed  freely  from  them  all, 
especially  when  the  normal  ones  were  being  sucked.  A  mole-like  body  on 
the  right  supernumerary  breast  gave  the  appearance  of  a  third  nipple.  The 
patient  said  she  first  noticed  the  supernumerary  glands  at  about  the  time  of 
puberty,  and  that  they  had  always  enlarged  and  given  milk  under  the  same 
conditions  as  the  normal  mammas.  She  had  never  brought  forth  more  than 
one  child  at  a  birth.  The  generative  organs  were  normal.  There  was  no 
history  of  any  similar  deformity  among  her  relations. 

(2)  Lee's  patient'"^  was  a  woman,  aged  35,  in  whom  a  pair  of  super- 
numerary mammae  were  noticed  shortly  after  her  premature  delivery  of  a 
still-born  child.  The  redundant  glands  were  situated  just  above  and  external 
to  the  normal  ones  ;  each  had  a  single,  small,  flat  nipple  which  yielded  milk. 
She  first  noticed  the  deformity  shortly  after  her  first  confinement  ten  years 


'""  Dublin  Med.  Journal,  vol.  v.,  1848,  p.  266. 
'"'   Med,  Chir.  Trans. ,  vol.  xxi.,  p.  266. 


70  POLYMASTIA. 

previously.     She  subsequently  had  several  single  children  ;    and  at  30  she 
had  twins.     The  generative  organs  were  normal. 

(3)  In  Gardiner's  case'"-  the  patient  was  a  mulattress  from  the  Cape,  aged 
29,  healthy  and  well  developed,  except  that  she  had  a  pair  of  supernumerary 
mammae  a  little  above  and  external  to  the  normal  ones.  The  redundant 
mammas  were  smaller  than  the  normal  ones — about  the  size  of  those  of  a 
girl  at  puberty.     After  child-birth  these  glands  enlarged  and  gave  milk. 

(4)  Champneys'"''  has  observed  in  a  lying-in  woman  a  rudimentary  nipple 
in  the  like  situation  just  above  the  right  breast.  This  woman  had  also  an 
extra  pectoral  pair  of  nipples  below  and  internal  to  the  normal  ones. 

As  examples  of  supernumerary  mammary  structures  in  a 
position  above  and  external  to  that  described  in  the  foregoing 
cases ;  yet  not  in  the  axilla,  but  over  the  middle  of  its  anterior 
border,  corresponding  to  the  second  pair  of  my  diagram  (fig.  10), 
I  can  cite  the  following  cases  : — 

(i)  Quinquad's '"^  patient  was  a  woman,  aged  24,  who,  in  addition  to  a 
large  pair  of  normal  mamm^,  had  another  smaller  pair  situated  above  them, 
over  the  middle  of  each  anterior  axillary  border.  Each  was  the  size  of  a 
small  orange,  and  was  furnished  with  well-formed  nipple  and  areola.  Dur- 
ing lactation  these  glands  gave  milk.  She  had  suffered  from  right  internal 
strabismus  since  the  age  of  two.  There  was  no  history  of  any  malformations 
among  her  relatives.  The  areolae  of  the  normal  mammai  were  very  large. 
Directly  I  saw  her  photograph  this  particular  recalled  to  mind  Cuvier's  cele- 
brated drawing  of  the  Hottentot  Venus'"''  whose  areola;  were  over  four 
inches  in  diameter. 

(2)  Bruce'""  has  seen  a  man  with  a  pair  of  rudimentary  supernumerary 
nipples  in  the  like  position,  who  had  also  an  extra  nipple  on  the  left  side 
below  the  normal  one. 

(3)  A  woman  observed  by  Charpentier'"'  with  a  pair  of  well-formed 
supernumerary  mamm;c  situated  over  the  middle  of  the  anterior  border  of 
each  axilla.  The  additional  mammie  differed  only  from  the  normal  ones  in 
that  they  were  smaller  ;  they  had  well  formed  nipples,  whence  milk  escaped 
on  pressure.     The  description  is  accompanied  by  a  good  figure. 

The    connection    between    pectoral    and    axillary  mamma; 


'"■-  Cited  by  Percy  in  his  "Mem.  sur  les  femmesmultimammce,"  Journal cie M€d., 
iSr^f.,  de  Corvisart.,  ann.  xiii.,  t.  ix.,  p.  383. 

""  op.  cii.,  p.  434- 

""  "  Femme  Tetramaze."'     Rev.  pholo.  des  Hop.,  1S70,  p.  16. 

""  "  Femme  de  race  boschismanne."  Hist.  nat.  des  mainmifercs,  St.  Milaire  et 
Cuvier,  t.  i.,  1824,  p.  1. 

'""  Op.  ciL,p.  425. 

""  Traitc pratique  des  Aiconcheinents,  I.  i.,  1889,  p.  69. 


AXILLARY     MAMMARY    STRUCTURES.  7 1 

is    admirably    illustrated    by   the   five  following  rare  cases   of 
multiple  mammai  •}^^ — 

(i)  Fitzgibbon's'""  patient  was  a  man,  aged  24,  a  native  of  Jamaica,  who 
had  four  supernumerary  mamniEe  :  a  well-formed  pair  below  and  internal  to 
the  normal  ones  ;  and  another  rudimentary  pair  just  above  and  slightly 
external  to  the  normal  ones. 

(2)  In  Mortillet's^'"  case,  two  pairs  of  supernumerary  mammse  were  also 
present,  but  both  were  situated  below  and  internal  to  the  normal  ones. 
The  lowest  pair  was  placed  on  the  upper  part  of  the  abdominal  wall,  in  the 
position  of  the  seventh  pair  of  my  diagram  (fig.  10)  ;  the  other  pair  was 
situated  between  the  foregoing  and  the  normal  pair,  probably  in  the  position 
of  the  fifth  pair  of  my  diagram,  but  as  to  this  the  description  is  not  very 
precise.  The  patient  was  a  healthy  young  conscript,  and  there  was  no 
history  of  any  hereditary  malformation  in  his  family.  The  supernumerary 
mammae  were  only  a  little  less  perfect  than  the  normal  ones.  The  lowest 
pair  was  the  smallest. 

(3)  Alexander's  patient'"  was  a  tall,  stout  mulatto  from  the  United  States. 
He  was  admitted  into  hospital  at  St.  Helena,  with  self-inflicted  flesh  wounds 
of  the  chest,  done  to  avoid  going  to  sea  with  his  ship.  On  examination  it  was 
noticed  that  he  had  six  nipples,  in  two  vertical  lines,  three  on  each  side,  the 
distance  between  them  from  above  downwards  being  about  four  inches. 
The  uppermost  pair  were  in  the  normal  position  ;  the  second  pair  corres- 
ponded to  the  fifth  of  my  diagram  (fig.  10),  and  the  third  pair  to  the  seventh 
of  the  diagram.  He  was  discharged  a  few  days  later,  but  returned  shortly 
afterwards,  having  deliberately  broken  his  forearm  to  avoid  going  on 
board  his  ship.  Beyond  this  mutilating  tendency  and  a  rather  ferocious 
aspect,  he  seemed  otherwise  normally  constituted.  His  mother  had  four 
supernumerary  mammse  in  similar  positions  to  his  own,  and  two  of  them 
secreted  milk.  Of  his  several  brothers  and  one  sister,  all  (except  one 
brother)  had  the  like  malformation. 

(4)  Amnion's'^-  patient,  with  three  pairs  of  supernumerary  mammary 
structures,  was  a  soldier,  22^  years  old,  in  a  Baden  infantry  regiment.  The 
positions  occupied  by  these  anomalous  structures  have  already  been  suffi- 
ciently described  (^.  v.  p.  46).  The  highest  and  the  lowest  pairs  were  the 
least  perfect. 

(5)  Neugebauer's^'^  case  is  remarkable  for  the  large  number  of  super- 
numerary structures  present,  viz.,  eight,  the  largest  number  yet  seen  in  any 


108  petrone  (Pro§.  Med.  Napoli.,  iii.,  1889,  516)  has  recorded  another  case  of  six 
nipples  in  a  male,  but,  as  I  have  been  unable  to  get  access  to  the  original  memoir,  I 
am  unable  to  state  the  precise  distribution  of  the  redundant  nipples. 

'"•'  Dublin  Quarterly  Journal  I\Ied.  Set.,  vol.  xxix. ,  i860,  p.  109. 

""  Btcll.  de  la  Soc.  d' Anthropologie,  t.  vi.,  1883,  p.  458. 

'"  Medical  Times  and  Gazelle,  vol.  ii.,  1855,  p.  70. 

"-  Cited  by  Bonnet,  in  Merkel  and  Bonnet's  Ergehrisseder  Anat.  u.  Eniwickelungs- 
geschichte,  Bd.  ii.,  1893,  S.  604. 

"^  Cent./.  Gyndk.,  1S86,  S.  729. 


72  POLYMASTIA. 

human  being^.  This  anomaly  was  met  with  in  the  person  of  a  single  woman 
of  Warsaw,  a  domestic  servant,  who  was  admitted  into  the  lying-in  hospital 
for  her  second  confinement.  H'er  normal  mammae  were  large  and  well 
formed,  and  during  lactation  they  gave  an  abundant  supply  of  milk.  Soon 
after  her  confinement,  when  suckling,  she  noticed  an  uncomfortable  wetness 
in  each  axilla.  On  examination  as  to  its  cause,  a  supernumerary  nipple 
without  areola  was  found  in  each  axilla,  from  which  milk  flowed  freely  when 
the  child  sucked  either  of  the  normal  breasts.  At  the  same  time  two  other 
pairs  of  nipples,  each  with  its  own  areola,  were  found  above  the  normal  ones. 
The  upper  pair  was  situated  over  the  middle  of  each  anterior  axillary  border  ; 
and  the  lower  pair,  just  above  the  periphery  of  each  bosom,  and  slightly 
external  to  the  normal  nipples.  Shortly  afterwards,  on  raising  the  pendent 
mammee,  two  other  unsymmetrical  redundant  nipples  were  found  below  and 
internal  to  the  normal  ones  ;  that  on  the  right  side  was  immediately  below 
the  bosom,,  that  on  the  left  was  some  inches  lower  down.  Neugebauer 
has  spoken  of  these  two  unsymmetrical  nipples  as  a  pair.,  but  it  is  quite  clear 
to  me  that  this  is  a  mistake  ;  the  upper  one  evidently  represents  the  right 
nipple  of  the  fifth  pair  of  my  diagram,  and  the  lower  one  the  left  nipple  of 
my  sixth  pair  (fig.  lo).  On  pressure,  milk  escaped  fi-om  all  these  redundant 
nipples.  It  is  a  curious  fact  that  after  her  first  confinement — seven  years 
previously — she  never  noticed  any  abnormality  about  the  chest,  other  than 
the  presence  there  of  several  brown  spots,  which  she  took  for  moles.  The 
patient  was  exhibited  at  a  meeting  of  the  Warsaw  Medical  Society.  A 
woodcut,  from  a  photograph,  which  accompanies  the  record  of  this  case, 
makes  it  very  complete. 

Of  true  atavistic  supernumerary  mammary  structures  z« ///^ 
axilla^  I  am  only  able  to  cite  the  four  following  cases,  to  which 
Neugebauer's  must  be  added.  This  shows  that  the  anomaly 
is  of  extreme  rarity  in  this  situation. 

(i)  In  a  case  observed  and  figured  by  Leichtenstern"^  there  was  a  nipple 
the  size  of  a  split  pea,  without  areola,  at  the  top  of  the  left  axilla  ;  and  con- 
nected with  it  was  a  mass  of  gland  substance  the  size  of  a  walnut.  The 
patient  was  a  woman  recently  delivered  of  her  first  child.  When  suckling, 
milk  escaped  from  this  nipple,  as  well  as  from  another  supernumerary  nipple 
just  below  and  internal  to  the  left  breast,  though  no  gland  substance  could 
be  felt  beneath  the  latter. 

(2)  A  similar  case  has  been  recorded  by  D'Outrcpont."-^  The  patient 
was  a  pregnant  woman  with  a  tumour  the  size  of  a  hen's  c^<g  in  the  left  axilla, 
connected  with  which  was  a  nipple,  whence  colostrum  escaped. 

(3)  Perrymond'"'  has  related  the  case  of  a  woman,  aged  27,  who  shortly 
after  her  second  confinement  noticed  a  tumour  the  size  of  a  pigeon's  t.g^  in 


Arch./,  path.  Anat.,  &c.,  Bd.  Ixiii.,  p.  245,  No.  38,  taf.  iv.,  fig.  i. 

Neue  Zeit.  f.  Geburtsk,  ^'c,  Hersang  von  Busch,  &c. ,  Bd.  ix.,  1840,  S.  40. 

L^ Union  Med.,  1874,  ••■  xviii.,  p.  864. 


PARAMAMMARY    NEOPLASMS.  73 

the  right  axilla.  It  was  movable,  and  not  connected  with  the  breast.  Over 
it  was  a  small  nipple  surrounded  by  an  areola.  On  pressure,  milk  escaped. 
The  tumour  was  first  noticed  about  the  time  of  puberty  at  the  age  of  14.  At 
her  first  confinement  it  was  taken  for  an  abscess.  Six  weeks  after  delivery 
the  secretion  ceased,  and  the  tumour  diminished  in  size. 

(4)  In  Godfrain's^''  case  the  patient  was  a  lying-in  woman,  aged  25,  who 
a  few  days  after  her  second  confinement,  noticed  a  tumour,  the  size  of  a 
fowl's  egg,  in  each  axilla.  Each  tumour  appeared  to  be  connected  with  the 
main  gland  by  a  pedicle,  and  over  each  there  was  a  rudimentary  nipple 
and  areola. 

In  animals  axillary  mammae  are  most  exceptional,  but  they 
are  met  with  in  the  pteropi  (fruit  bats)  and  in  the  flying  lemur 
{galeopithecus). 

S  V. On  Paramammary   Neoplasms  arising  from  Supernumerary   Mammary 

Structures. 

It  has  been  maintained  by  Cohnheim,  that  in  the  develop- 
ment of  every  part  of  the  body,  portions  of  the  matrix  become 
sequestrated  and  remain  disseminated  in  the  adjacent  tissues. 
He  ascribes  the  origin  of  all  neoplasms  to  belated  rudiments  of 
this  kind.  To  Cohnheim's  theory  it  has  been  objected,  that  no 
evidence  of  such  an  amount  of  developmental  irregularity  as 
it  presupposes,  has  ever  been  demonstated.  At  one  time  I 
thought  there  was  some  force  in  this  objection,  but  a  more 
thorough  examination  of  the  subject,  in  the  light  of  modern 
research,  has  convinced  me  that  it  is  not  so;  for  sequestrated 
fragments  of  the  kind  alleged  have  now  been  shown  to  exist 
in  every  part  of  the  body,  that  has  been  specially  examined  for 
them. 

Hitherto  the  breast  has  seemed  to  be  an  exception  to  this 
rule,  but  from  the  facts  set  forth  in  the  preceding  section,  and 
from  such  as  I  will  now  proceed  to  mention,  it  is  obvious  that 
paramammary  sequestrations  are  of  common  occurrence ;  and 
that  from  them  neoplasms — identical  in  structure  with  mam- 
mary neoplasms — frequently  arise. 

Considering  the  importance  of  this  subject,  it  is  astonishing 

'"  These  de  Paris,  1877,  p.  35. 


74  POLYMASTIA. 

how  little  attention  it  has  hitherto  received.  Oilier,  of  Lyons, 
was  one  of  the  first  who  specially  directed  attention  to  the 
occurrence  in  the  vicinity  of  the  mammary  gland  of  isolated 
encapsuled  masses  of  mammary  glandular  tissue  arising  in 
this  way.  The  enlargement  of  such  rudiments,  consequent  on 
inflammatory  or  neoplastic  action,  gives  rise  to  the  various 
paramammary  tumours,  as  in  the  following  cases. 

A  patient  of  OUier's'"*  a  single  woman,  aged  20,  had  a  hard,  nodulated, 
mobile  tumour,  the  size  of  a  walnut,  above  and  external  to  the  left  bosom, 
and  quite  independent  of  the  mamma.  It  was  excised,  when  it  was  found 
to  be  encapsuled,  and  unconnected  with  the  adjacent  parts.  On  micro- 
scopical exami7iation  it  consisted  chiefly  of  fibrous  tissue,  in  which  mammary 
gland  structures  (ducts  and  acini)  were  embedded.  The  tumour  was  of  one 
and  a-half  year's  duration,  and  it  was  first  noticed  six  months  after  a  blow. 

In  a  similar  case  by  Labbe  and  Coyne,""  the  patient,  a  woman,  aged  40, 
had  a  hard,  nodulated,  mobile  tumour,  the  size  of  a  pigeon's  ^%%,  to  the 
axillary  side  of  the  right  breast,  and  so  close  to  the  axilla  that  it  was  at  first 
mistaken  for  an  enlarged  axillary  lymphatic  gland.  It  had  no  connection 
whatever  with  the  mamma.  This  was  verified  when  the  tumour  was  dis- 
sected out  ;  it  was  completely  encapsuled,  and  histologically  consisted  of 
dilated  tubular  and  acinous  mammary  glandular  structures  embedded  in 
hyperplastic  fibrous  stroma. 

In  dissecting  a  breast.  Eve'-"  found  a  firm  nodule,  about  the  size  of  a 
hazel  nut,  lying  near  its  axillary  border,  but  completely  detached  from  it. 
Microscopical  examination  revealed  large  ducts,  lined  with  short  columnar 
epithelium,  in  places  greatly  dilated.  There  were  also  present  other  smaller 
ducts,  which  ended  in  acini.  These  structures  were  embedded  in  fibrous 
stroma.  The  tumour  was  in  all  respects  just  like  an  accessory  mammary 
glandule.  The  patient  was  a  woman,  aged  59,  who  died  of  bronchitis,  after 
removal  of  an  epulis  of  the  lower  jaw.  In  addition  to  this  tumour  she  had 
at  the  upper  and  inner  part  of  each  breast  a  small  ordinary  adenoma. 

Liicke'-'  has  seen  cases  of  the  same  kind. 

Forbes'"  mentions  an  instance  of  cystic  adeno-sarcoma,  that  sprang  from 
one  of  these  sequestrations. 

Cameron'^'^  has  related  the  two  following  examples  : — 

In  the  first  the  patient  was  a  single  woman,  aged  30,  who,  five  years  pre- 
viously, had  noticed  a  lump  the  size  of  a  walnut  in  her  right  axilla. 


'"*  Gaz.  Mid.  de  Lyon,  1855,  p.  144. 

""  Trait i  des  Tumours  Bhiignes  du  Sein.,  Paris,  1876,  p.  131. 

'■"'  Brif.  ATed.  Journal,  vol.  i.,  1883,  p.  298. 

'='  Pith.-Billr.  Hdb.,  Bd.  ii.,  S.  281. 

^'"  Phil.  Medical  News,  March  5,  1892. 

'■'■'  Jo'ifual  of  Anatomy,  vol.  xiii.,  1879,  p.  150. 


PARAMAMMARY    NEOPLASMS.  75 

On  examination,  there  was  found  in  this  situation  an  ovoid,  elastic  tumour, 
the  size  of  a  large  cricket  ball.  It  had  been  rather  painful  for  the  last  two 
years.  The  tumour  was  excised.  There  was  no  difficulty  in  the  operation, 
because  it  was  encapsuled,  and  readily  shelled  out.  On  section,  after  re- 
moval, it  looked  like  a  fibro-lipoma  ;  but  on  microscopic  examination  it 
proved  to  be  an  ordinary  fibro-adenoma. 

In  the  second  case  the  patient  was  also  a  single  woman,  aged  33.  She 
had  a  tumour,  "  the  size  of  the  fist,  in  the  axilla."  It  had  not  increased  in 
size  since  puberty.     No  operation  was  done. 

In  the  Museum  of  University  College  I  have  found  an  in- 
teresting specimen  of  this  condition,  which  is  thus  described  in 
the  Catalogue.^^* 

"A  large  tumour  removed  from  the  mammary  region.  It  is  rounded  in 
form,  and  measures  five  inches  in  its  long  diameter.  Its  surface  is  slightly 
lobulated,  and  it  is  enclosed  in  a  loose  capsule  of  areolar  tissue.  The  section 
shows  the  tumour  to  be  composed  of  closely  packed  lobules,  bound  together 
by  a  moderately  abundant  fibrous  stroma.  The  resemblance  to  a  section  of 
the  pancreas  is  almost  perfect.  There  is  one  cyst,  about  half  an  inch  in 
diameter,  seen  in  the  section.  It  has  some  fine  papillary  intra-cystic  growths 
projecting  into  it.  The  tumour  was  removed  by  Quain  from  a  lady,  aged  26, 
the  mother  of  several  children.  It  was  first  noticed  eighteen  months  before 
operation  ;  and  during  the  last  six  months  it  had  increased  continuously. 
At  the  time  of  the  operation  the  lady  was  six  months  pregnant.  The 
tumour  was  on  the  left  side,  and  did  not  implicate  the  mamma,  which  was 
quite  free  from  it.  After  removal  it  weighed  four  pounds.  On  microscopic 
examination  the  tumour  was  seen  to  be  composed  of  a  structure  closely 
resembling  that  of  the  normal  mamma.  Groups  of  acini  were  present,  lined 
with  abundant  epithelium,  which  in  some  places  quite  filled  them  up.  Here 
and  there  small  ducts  were  seen  which  communicated  with  the  acini  ;  but  no 
large  ducts  were  seen  which  received  the  smaller  ones.  The  inter-acinous 
tissue  was  very  abundant,  and  consisted  of  mature  fibrous  tissue.  No  fat 
was  found  in  any  part  of  the  specimen." 

Beyond  the  foregoing  scattered  facts,  which  are  now  for  the 
first  time  brought  together,  very  little  has  been  recorded  as  to 
the  development  of  neoplasms  from  supernumerary  mammary 
structures. 

Having  made  this  subject  the  object  of  special  investigation 
during  several  years,  I  have  arrived  at  the  following  results  : — 

Of  fifty  cases  of  Fibro-adenoma  of  the  mammary  region 
consecutively  under  my  observation,  I  found  that  seven  (14  per 


'-'  Vol.  ii.,  1887,  p.  445,  No.  i960. 


76  POLYMASTIA. 

cent.)  had  originated  in  supernumerary  mammary  structures, 
quite  outside  the  normal  mammae.  I  append  brief  abstracts  of 
these  cases : — 

(i)  A  well-formed,  healthy,  single  woman,  aged  36,  a  cook,  had  a  hard, 
circumscribed,  ovoid  tumour,  the  size  of  a  bantam's  egg  just  above  and  ex- 
ternal to  the  right  bosom.  There  was  no  connection  between  the  tumour 
and  the  mammary  gland  ;  and  it  was  free  from  adhesions  with  the  adjacent 
structures.  The  nipple  and  axillary  lymph  glands  were  normal.  The 
patient  said  she  first  noticed  a  small  lump  in  the  site  of  the  present  tumour 
six  months  previously.  There  was  no  history  of  previous  injury  or  disease 
of  the  part.  Her  mother  died  of  cancer  of  the  left  breast.  The  catamenia 
had  always  been  regular.  During  the  last  few  years  she  had  been  subject 
to  bilious  dyspeptic  attacks  ;  but  otherwise  her  previous  health  had  been 
very  good. 

The  tumour  was  dissected  out.  It  was  encapsuled  and  solid,  and  un- 
connected with  the  mamma.  It  presented  to  the  naked  eye  the  ordinary 
appearance  of  fibro-adenoma. 

On  microscopic  examination  acini  and  ducts  were  seen  embedded  in  fibro- 
fatty  tissue.  The  acini  were  arranged  in  grape-like  clusters,  as  in  the 
normal  mamma  ;  but  most  of  their  cells  were  in  granular  degeneration, 
and  in  some  places  small  cysts  had  formed.  The  ducts  were  seldom  ex- 
cavated, and  their  cells  were  also  in  granular  degeneration. 

(2)  A  well-nourished  single  woman,  aged  38,  with  a  hard,  movable,  cir- 
cumscribed tumour,  the  size  of  a  large  walnut,  just  above  the  right  bosom. 
No  enlargement  of  the  adjacent  lymph  glands.  Slight  congenital  retraction 
of  both  nipples.  The  tumour  was  first  noticed  three  weeks  previously.  No 
injury  or  known  cause  for  it.  Catamenia  always  regular.  Previous  health 
good.  Her  father  died,  aged  69,  of  cancer  of  the  stomach  ;  and  she  has 
lost  a  sister  with  cancer  of  the  breast. 

The  tumour  was  dissected  out.  It  proved  to  be  a  typical,  solid  fibro- 
adenoma, unconnected  with  the  breast. 

(3)  A  pale,  fair  woman,  aged  26,  with  two  small,  hard,  nodular  tumours 
above  the  left  bosom,  and  entirely  unconnected  with  the  gland.  The  nipple 
and  adjacent  lymph  glands  normal.  The  tumours  of  three  months'  duration. 
The  patient  had  been  twice  married.  By  her  first  husband  she  had  one 
child  and  two  miscarriages.  Her  previous  health  had  been  good.  She  lost 
her  mother  of  "  internal  tumour." 

The  tumours  were  dissected  out.  Each  had  the  appearance  of  ordinary 
filiro-adenoma.  On  microscopic  examinatioti  glandular  acini  in  the  resting 
stage  were  seen,  surrounded  by  nucleated  fibrous  tissue,  which  contained  a 
few  spindle  cells. 

(4)  A  healthy-looking  woman,  aged  43,  who  had  on  the  axillary  side  of 
the  left  breast,  and  unconnected  with  it,  a  smooth,  hard,  movable  tumour, 
the  size  of  a  walnut.  No  enlargement  of  the  adjacent  lymph  glands.  It 
was  first  noticed  two  months  previously.  Both  nipples  were  congenitally 
retracted.  Catamenia  regular.  The  tumour  was  excised — a  typical  solid, 
encapsuled  lil)ro-adciu)inu. 


PARAMAMMARY    NEOPLASMS.  "]"] 

(5)  A  healthy  woman,  aged  40,  with  a  hard,  racemose  tumour,  the  size  of 
a  walnut,  over  the  edge  of  the  sternum,  on  the  left  side,  quite  outside  the 
mamma.  It  was  first  noticed  three  years  previously.  The  patient  had 
married  at  21,  and  had  cohabited  with  her  husband  ever  since,  but  she  had 
never  been  pregnant.  On  examination  of  the  tumour  after  removal,  it  was 
found  to  be  an  encapsuled,  loculated  fibro-adenoma.  The  loculi  were  full  of 
papillary  ingrowths.  On  microscopic  exavimation  fibro-adenoma — the  intra- 
locular  growths  consisted  of  fibrous  processes  lined  with  cubical  epithelium. 

(6)  A  single  woman,  aged  27,  a  dressmaker,  with  a  circumscribed  tumour, 
the  size  of  a  hazel  nut,  over  the  edge  of  the  sternum  on  the  right  side,  and 
unconnected  with  the  mamma.  It  was  first  noticed  nine  months  previously. 
The  tumour  was  dissected  out,  and  it  proved  to  be  a  solid  ordinary  fibro- 
adenoma. 

(7)  A  single  woman,  aged  32,  who  had  a  firm  nodular  tumour,  the  size  of 
a  walnut,  just  below  and  quite  outside  the  left  bosom.  It  was  first  noticed 
two  years  previously.  Her  sister  had  a  similar  mammary  tumour.  It  was 
dissected  out,  and  proved  to  be  an  ordinary  solid,  encapsuled  fibro-adenoma, 
unconnected  with  the  mamma. 

With  regard  to  the  development  of  Cancer  from  super- 
numerary mammary  structures,  I  have  the  following  observa- 
tions to  record  : — 

Of  132  cases  of  cancer  of  the  mammary  region  in  women, 
consecutively  under  observation,  I  found  that  thirteen  (9-8  per 
cent.),  had  originated  in  supernumerary  mammary  structures, 
quite  outside  the  normal  mammae. 

Subjoined  are  brief  abstracts  of  these  cases  : — 

(i)  Single,  aged  50.  Six  months  previously  she  first  noticed  a  lump  in 
the  sternal  side  of  left  breast.  On  examination,  a  hard,  nodular,  cancer- 
ous tumour,  the  size  of  a  walnut,  in  this  situation,  quite  outside  the  mamma. 
The  overlying  skin  adherent  ;  no  obvious  affection  of  the  adjacent  lymph 
glands.  Amputation  of  the  breast,  and  removal  of  the  tumour  with  it.  No 
history  of  tumour  or  cancer  in  the  family. 

(2)  Single,  aged  71.  Seven  years  previously  a  hard  nodule  first  noticed 
at  the  upper  part  of  the  chest,  some  distance  above  the  left  bosom.  Six 
years  ago  the  breast  amputated,  and  the  tumour  removed.  Recurrence  at 
the  primary  seat  five  years  later.     No  history  of  tumour  or  cancer. 

(3)  Single,  aged  29.  Two  years  previously  first  noticed  a  hard  lump,  the 
size  of  a  pea,  above  the  left  bosom  and  unconnected  with  the  gland.  In  the 
course  of  four  months  it  increased  to  the  size  of  a  marble.  It  was  then 
excised  ;  but  the  breast  was  left.  Recurrence  at  the  primary  seat  six  weeks 
later  ;  this  again  excised.  Nine  months  later  further  recurrence  in  the 
same  locality.  On  examination,  a  hard  lump,  the  size  of  a  brazil  nut,  above 
the  left  breast  over  the  second  intercostal  space.  The  breast  still  quite  free. 
Several  small  hard  glands  above  and  below  clavicle.     Just  below  the  tumour 


y8  POLYMASTIA. 

are  the  scars  of  the  former  operations.  Axillary  glands  free.  The  recurrent 
disease  again  freely  excised.  She  was  convalescent  twenty-four  days  later, 
and  I  have  not  seen  her  since.  No  history  of  cancer  or  tumour  in  the 
family. 

(4)  Single,  aged  45.  Quite  below  the  left  breast,  on  its  axillary  side,  is  a 
hard,  fixed,  nodular  tumour,  with  the  overlying  skin  infiltrated  and  ulcerated. 
The  disease  was  first  noticed  a  year  previously,  when  it  presented  as  a  lump 
the  size  of  a  hazel  nut.  The  axillary  glands  enlarged.  No  history  of  cancer 
or  tumour.     Breast  amputated,  the  tumour  and  axillary  glands  removed. 

(5)  Aged  54,  married  at  42,  never  pregnant.  At  the  lower  and  axillary 
side  of  the  right  breast,  quite  outside  the  gland,  is  a  hard,  knobby,  rounded 
tumour,  the  size  of  a  small  orange.  Nipple  normal  ;  overlying  skin  ad- 
herent. Axillary  glands  enlarged.  The  tumour  was  first  noticed  one  year 
previously.  No  history  of  cancer  or  tumour.  Amputation  of  breast  ;  re- 
moval of  tumour  and  axillary  glands. 

(6)  Single,  aged  46.  Above  the  left  breast,  and  on  its  inner  side,  is  a 
hard,  nodular  tumour  the  size  of  a  bantam's  egg,  qtiite  outside  the  mamma. 
Nipple  normal  ;  overlying  skin  adherent  ;  axillary  glands  slightly  enlarged. 
First  noticed  four  months  previously.  Amputation  of  breast  with  the 
tumour  and  removal  of  axillary  glands.  No  family  history  of  cancer  or 
tmmour. 

(7)  Married,  mother  of  three  children,  aged  51.  Above  the  right  bosom, 
over  the  middle  of  the  anterior  axillary  fold,  is  a  hard,  nodular  tumour,  the 
size  of  a  hen's  egg,  quite  outside  the  mamma.  The  overlying  skin  adherent  ; 
the  axillary  lymph  glands  enlarged.  Duration  of  tumour  eighteen  months. 
Removal  of  breast,  tumour  and  axillary  glands.  No  family  history  of  tumour 
or  cancer. 

(8)  Married,  four  children  and  one  miscarriage,  age  67.  Three  years 
ago  first  noticed  a  hard  tumour  at  the  sternal  side  of  left  bosom,  unconnected 
with  the  gland.  Three  months  later  it  was  excised,  but  the  breast  was  not 
removed.  Recurrence  set  in  at  the  primary  seat  six  weeks  ago.  On  ex- 
amination over  the  edge  of  sternum,  on  the  left  side,  quite  outside  the 
mamma,  is  a  tumour,  the  size  of  a  walnut,  in  the  old  scar.  Nipple  normal  ; 
no  enlargement  of  axillary  glands.  Amputation  of  breast  and  removal  of 
tumour. 

(9)  Single,  aged  64.  Over  the  edge  of  the  sternum,  on  the  left  side,  is  a 
hard,  rounded  tumour,  the  size  of  an  orange,  firmly  adherent  to  the  adjacent 
structures.  The  lymph  glands  of  left  axilla  enlarged.  The  patient  says  the 
disease  began  as  a  lump,  quite  outside  the  breast,  eighteen  months  ago. 
No  family  history  of  cancer  or  tumour.     No  operation. 

(10)  Single,  aged  49.  Four  and  a-half  years  ago  a  hard  lump  first 
noticed  quite  outside  the  left  bosom,  near  the  axilla.  A  fortnight  later  breast 
amputated  and  tumour  removed.  Recurrence  at  primary  seat  and  in  axilla 
two  years  later.     Her  sister  died  of  cancer  of  the  breast. 

(u)  Married,  six  children,  aged  47.  Above  the  left  breast,  over  the 
edge  of  the  sternum,  is  a  hard  tumour  the  size  of  a  walnut,  quite  outside 
the  bosom.  It  is  adherent  to  the  adjacent  parts.  Nip])le  retracted;  axillary 
glands  full.      The  patient  says  she  first  noticed  a  lump  in  site  of  present 


PARAMAMMARY    NEOPLASMS.  79 

disease,  outside  the  breast,  two  years  ago.  Amputation  of  breast  and  re- 
moval of  tumour  ;  axilla  not  touched.  No  family  history  of  cancer  or 
tumour. 

(12)  Single,  aged  62.  Over  the  right  edge  of  sternum,  opposite  the  middle 
of  the  breast,  but  unconnected  with  it,  is  a  hard  tumour  the  size  of  an  orange. 
The  overlying  skin  is  infiltrated,  and  the  axillary  glands  are  enlarged.  The 
disease  was  first  noticed  two  years  ago  as  a  tumour  the  size  of  a  hazel  nut, 
over  the  edge  of  the  sternum.  Congenital  contraction  of  the  nipple.  No 
family  history  of  cancer  or  tumour.  Breast  amputated,  tumour  removed 
and  axilla  cleared. 

(13)  Single,  aged  69.  Pale  and  weak.  Just  beyond  the  periphery  of 
the  axillary  part  of  the  right  bosom  is  a  hard,  nodular  tumour,  the  size  of 
a  small  orange.  The  overlying  skin  adherent ;  axillary  lymph  glands 
enlarged.  Duration  five  years.  Breast  amputated,  tumour  removed  and 
axilla  cleared. 

Among  these  132  cases  there  were  a  few  others,  in  which 
it  seemed  almost  certain  that  the  disease  originated  quite 
outside  the  mamma,  but  as  I  could  not  be  quite  sure  of  it  I 
have  omitted  them. 

With  regard  to  the  literature  of  the  subject : — 

Foerster  ^^^  has  cited  a  case  by  Busch,  in  which  cancer  developed  in  a 
supernumerary  mammary  structure  in  the  neighbourhood  of  the  axilla. 
The  breast  was  amputated  and  the  axillary  cancer  was  dissected  out.  On 
examination  after  removal,  the  mammary  gland  was  found  to  be  uncon- 
nected with  the  axillary  tumour,  and  free  from  the  disease.  In  connection 
with  the  cancerous  tumour,  some  of  the  supernumerary  axillary  mammary 
tissue  still  remained  uninvaded  by  the  disease.  On  microscopic  exa}ni?ta- 
tion  this  was  seen  to  consist  of  glandular  tissue,  just  like  that  of  the 
normal  mamma. 

Gluck'^*^  has  recorded  an  interesting  case  of  the  kind.  The  patient 
was  a  woman  who  for  twenty-eight  years  had  been  affected  with  a  hard 
freely  movable  tumour,  quite  above  the  mamma.  This  swelling,  after  re- 
maining stationary  for  many  years,  subsequently  increased  much,  and 
presented  all  the  appearances  of  cancer.  The  tumour  was  then  excised 
and  it  was  evidently  cancerous,  as  it  recurred  two  years  later.  Here  we 
have  an  enlarged  supernumerary  mammary  structure,  from  which  cancer 
subsequently  originated. 

In  the  Hunterian  Museum'-'  is  half  a  cancerous  tumour,  removed  from 
the  axilla  of  a  lady,  aged  35.  The  breast  and  the  skin  over  it  were 
normal.  It  was  easily  detached.  Microscopical  examination  revealed 
alveolar  cancer.  This  is  evidently  a  case  of  the  kind  we  have  been 
considerinsf. 


•^  Die  Missbild.  der  Mettsch.,  1861,  S.  49. 

'=«  Bfirlifi  klin.   IVoch.,  1885,  8.  292. 

'-"  Path.  Catalogue,  vol.  iv.,  p.  292,  No.  481 1  A. 


8o  POLYMASTIA. 

Since  the  above  was  written  I  have  seen  a  specimen  of  Willett's,'-*  in 
which  a  cancerous  tumour,  the  size  of  a  walnut,  of  four  or  five  years  growth, 
was  excised  from  just  below  the  right  clavicle.  It  was  quite  separate  from 
the  breast,  which  was  normal.  Histologically  its  structure  was  that  of 
acinous  mammary  cancer.      The  patient  was  an  elderly  lady. 

Most  of  the  alleged  cases  of  primary  cancer  of  the  axillary 

lymph  glands  belong  to  this  category.      The  following  case  by 

Nunn^^"  is  a  typical  instance  : — 

A  woman,  aged  60,  seven  months  previously  noticed  a  hard  lump,  the 
size  of  a  hazel  nut,  in  her  left  axilla.  A  month  later  the  breast  became 
hard.  Three  months  ago  the  arm  began  to  swell,  and  in  the  left  axilla  a 
hard,  cancerous  mass  had  formed.  Numerous  hard,  cancerous  tubercles 
had  disseminated  in  the  skin  over  the  tumour. 

The  two  examples  of  primary  scirrhus  of  the  axilla  in  men 
figured  by  Erichsen^^"  also  belong  here. 

Quite  recently  Martin^^^  has  published  an  account,  with 
interesting  remarks,  of  a  fibro- adenoma  developed  from  an 
atavistic  supernumerary  mammary  rudiment,  situated  below 
the  normal   left  mamma. 

Billroth^^^  mentions  having  seen  acinous  cancer  develop  in 
a  breast  with  two  nipples. 

The  treatment  of  neoplasms  thus  arising  must  be  conducted 
in  accordance  with  the  same  principles  that  guide  us  in  deal- 
ing with  corresponding  neoplasms  in  the  breast  itself. 

Much  valuable  information  on  the  subject  of  polymastism 
will  be  found  in  recent  publications  by  Schultze,^^^  Klaatsch/^* 
Wiedersheim,^-''''  Bardeleben,^^*^  Bonnet'^''  and  Hennig.^^^ 


■-*  Trans.  Path.  Socy.  Land.,  vol.  xlii.,  1891,  p.  319. 

'-'  Cancer  of  the  Breast,  1882,  p.  95. 

'■"'  Sdence  and  Art  of  Siiri^ery,  vol  ii.,  1872,  p.  50,  ft  seq. 

'="   Arch.f.  klin.  Chir.,  Bd.  xlv.,  1893,  •''•  ^^O- 

'•'-  Deutsche  Chir.,  Lief  41,  .S.  10. 

"^  Anat.  Anzeiger,  1892  ;  also  Verhaiidl.  d.    Phys.-vied.  Gesellsch.  z.  IViirzdur^, 

1893- 

'"  Morph.  Jahrh.,  1892  and  1893. 

'"  Der  Bail  des  Menschen,  &c. ,  Freiburg,  1893. 

'='"  Anat.  Anzeifier.,  Bd.  vi.,  1891,  S.  247  ;  also  1892,  No.  3,  S.  87.  Verhandl. 
d.Anat.  Ges.  Wien.,  1892,  S.  199;  also  1893,8.  191.  He  found  supernumerary 
mammary  structures  present  in  9  per  cent,  of  all  men,  and  in  4  per  cent,  of  all 
women,  examined. 

137   Merkel  and  Bonnet's  Ergebrisse  der  Anat.  u.  Eutwirkelumisgeschichte,  Bd.  ii., 

1893. 

""  Arch.f.  Anthrop.,  Bd.  xix.,  Ileft  3,  1890. 


PARAMAMMARY    NEOPLASMS.  01 

Schultze's  account  of  the  development  of  the  mammae  in 
the  cat,  fox,  rabbit,  rat,  pig  and  other  multimastic  animals 
is  particularly  interesting,  as  it  enables  us  better  to  under- 
stand many  of  the  previously  mentioned  anomalies.  He  finds 
that  in  these  animals  the  first  mammary  rudiment  presents  as 
a  linear  thickening  of  the  epidermis,  extending  on  each  side 
from  the  base  of  the  evolving  anterior  extremity  to  the  inguinal 
region,  and  lying  nearer  the  dorsal  than  the  ventral  surface. 
This  is  the  "mammary  ridge,"  or  common  rudiment  of  the 
mammary  glands.  Soon  spindle-shaped  thickenings  appear  in 
the  course  of  the  line,  corresponding  in  number  with  the 
mammjE  of  the  adult  form.  After  a  time  the  connecting 
strands  usually  disappear,  and  only  the  lenticular  thickenings 
are  left.  This  dorsal  position  of  the  mammary  rudiments  is 
not  long  retained,  for  migration  soon  takes  place  towards  the 
ventral  surface.  Probably  it  will  eventually  be  found  that  all 
mammals,  in  an  early  stage  of  development,  present  "mammary 
ridges,"  or  traces  of  them. 


82 


CHAPTER   V. 

Hypertrophy, 


S     I. Introductory. 

The  term  hypertrophy  is  commonly  used  in  a  very  loose 
manner,  especially  as  applied  to  the  breast.  Of  this  affection  in 
general,  two  forms  may  be  recognised  :  in  one  the  increase  of 
bulk  is  due  to  increase  of  function — physiological  hypertrophy  ; 
in  the  other  no  such  causal  relation  exists — pathological  hyper- 
trophy. The  former  condition  is  practically  unknown  as  a 
disease  in  the  breast  ;  it  is  solely  with  the  latter  that  we  now 
have  to  do. 

From  the  ontogenetical  standpoint  the  breast  is  one  of  the 
most  remarkable  organs  in  the  body,  for  most  of  its  essential 
morphological  features  are  evolved,  not  in  the  embryo,  but  at 
various  successive  periods  of  post-embryonic  life.  Thus  at 
different  epochs  its  structure  varies.  These  metamorphoses  are 
especially  noticeable  at  puberty  and  after  conception  ;  while  at 
the  climacteric  period  equally  striking  retrogressive  changes 
set  in.  It  is  in  connection  with  these  biological  processes 
that  the  phenomena  of  mammary  hypertrophy  may  be  most 
profitably  studied. 

Two  varieties  of  the  disease  are  met  with — the  diffuse  and 
the  ch'cuinscribed ;  in  the  former  the  whole  breast  is  affected, 
in  the  latter  only  certain  of  its  constituent  divisions.  The  diffuse 
form  is  certainly  very  rare,  for  while  2,422  cases  of  mammary 
neoplasms  came  consecutively  under  treatment  at  Middlesex, 
University  College,  Bartholomew's  and  Thomas'  Hospitals 
during  a  period  of  from  sixteen  to  twenty-one  years,  only 
six  cases  of  diffuse  hypertrophy  were  seen  in  the  same  period. 


INFANTILE    HYPERTROPHY.  83 

Both  sexes  are  liable  to  it  ;  but  in  males  the  enlargement  hardly 
ever  surpasses  the  size  of  the  normal  female  mamma,  and  the 
condition  is  not  of  grave  import. 

The  following  remarks  apply  exclusively  to  the  diseise  as 
it  affects  females. 

§     II. Infantile    Hypertrophy. 

Most  cases  begin  in  early  adult  life  ;  yet  there  are  on  record 
a  few  instances  in  which  mammary  hypertrophy  is  said  to  have 
been  congenital,  and  in  others  it  has  originated  in  early  infancy. 
In  most  of  these  we  evidently  have  to  do  with  exaggeration  of 
the  formative  processes  natural  to  the  mammae  during  the  first 
week  or  two  of  extra-uterine  life.  Cases  of  this  kind  differ 
essentially  from  those  of  the  adult  type,  for,  as  in  gynaeco- 
mostism,  the  breasts  having  attained  a  certain  size  then  cease 
to  increase. 

Such  a  case  is  Hewitt's,^  in  which  considerable  hypertrophy  of  both 
mammEe  was  noticed  one  week  after  birth,  and  this  increased  in  the  follow- 
ing week,  without  any  sign  of  inflammation  or  abscess,  the  child  being  in 
other  respects  normal. 

In  a  similar  case  related  by  Hahn,-  the  left  breast  was  affected,  and  both 
hands  were  hypertrophied. 

In  a  girl,  3I  years  old,  Grout^  saw  both  mammae  developed  like  those  of 
a  fully  grown  woman,  although  in  other  respects  she  resembled  children  of 
her  own  age. 

Most  cases  of  infantile  hypertrophy    have,    however,    been 

met  with  in  association  with  precocious  sexual  development.     In 

studying  these  it   must  be  borne  in   mind  that  in   the  tropics 

girls  attain  puberty  at  a  very  early  age,  often  at  8  years  or  even 

earlier.     The  following  cases  are  of  this  kind  : — 

In  a  child,  3  years  old,  Jacobovitch'  found  the  mammae  as  large  as  hen's 
eggs,  and  discharging  a  considerable  quantity  of  lactescent  fluid.  She  was 
also  subject  to  sanious  vaginal  discharge.  The  genitals  were  normal. 
When  next  seen  three  years  later,  menstruation,  with  the  usual  molimina. 


'  Lancet,   1837,  vol  i.,  p.  537. 

'  Schmidt'' s  J ahreshericht,  Bd.  v.,  S.  138. 

^  Arch.  Gen.  de  Med.,  1854,  t.  i.,  p.  758. 

■'  Nouv.  Arch.  d'Obstet.  et  de  Gyn.,  Sup.,  June,  1893. 


S4  HYPERTROPHY. 

had  become  of  frequent  occurrence,  and  her  breasts  were  as  large  as  small 
oranges.     The  labia  minora  and  clitoris  were  somewhat  enlarged. 

In  a  child  born  at  New  Orleans,  U.S.,  of  poor  white  parents,  Lebeau^ 
found  both  breasts  largely  developed  and  the  mons  veneris  covered  with 
hairs.  The  catamenia  appeared  when  she  was  3  years  old,  and  sub- 
sequently continued  regularly.     Each  breast  was  the  size  of  a  large  orange, 

In  the  south  of  France  Comarmond®  met  with  an  infant  3  months  old, 
who  had  breasts  like  those  of  a  woman  at  puberty,  hairs  on  the  pubes,  and 
the  catamenia  regularly  established. 

Ramon  de  la  Sagra^  has  related  the  case  of  an  infant  negress,  who  had 
very  large  breasts  from  birth,  and  some  months  afterwards  sanious  discharge 
from  the  genitals.  This  recurred  several  times  during  the  first  year,  and 
from  the  second  it  took  on  the  regular  periodicity  of  the  catamenial  flow. 
When  only  32  months  old,  she  had  all  the  signs  of  puberty  as  in  a  woman 
of  16. 

In  Mallet's  case,®  some  days  after  birth,  the  mammae  attained  the  size  of 
large  fowl's  eggs,  and  colostrum-like  fluid  could  be  expressed  from  them. 
The  external  genitals  were  unusually  well  developed,  and  there  was  sanious 
vaginal  discharge. 

Wilson's''  case  is  very  similar  to  the  foregoing.  At  birth  the  breasts  were 
the  size  of  fowl's  eggs.  In  the  course  of  the  next  five  months  they  increased 
to  the  size  of  those  of  a  young  woman  at  puberty.  At  this  time  the  cata- 
menia first  appeared.  When  6  years  old  she  was  fat,  with  breasts  like 
those  of  an  adult  woman,  and  the  pubes  was  covered  with  hairs. 

Mandelslot^"  mentions  having  seen  an  infant,  2  years  old,  with  breasts 
larger  than  those  of  an  adult  woman,  in  whom  menstruation  set  in  at  the 
age  of  three  years. 

I  have  given  prominent  attention  to  these  cases  because  they 
have  generally  been  overlooked  by  those  who  have  previously 
written  on  this  subject. 

The  following  case  furnishes  a  connecting  link  between 
such  cases  as  the  foregoing,  and  those  that  follow  in  the  next 
section. 

A  small,  ill-nourished  girl,  only  12  years  old,  exhibited  by  Sinclair"  at  the 
North  of  England  Obstetrical  Society.  Both  breasts  were  so  enormously 
hypertrophied,  that  each  was  estimated  to  weigh  about  ten  or  twelve  pounds. 

*  Gaz.  MM.  de  Paris,  1832,  p.  681. 
« Ibhi. 

'  Comptes  Rendtis  de  PAcad.  des  Sci.,  t.  61,  p.   570. 

*  Gaz.  Med.  de  Paris,    1832,  p.  620. 

*  Gaz.  des  Hop.,  1854,  p.   315. 

'"  Weiienwelier,  "  Uber  die  Hyp.  der  Briiste,"  in  Vierteljahr-schrift,  f.  d.  prakt, 
Heilk.  Prao,.,  1847,  Bd.  xiii.,  s.  80. 

"  Liverpool  Med.  Chir.  Journal,  Jan.,  lSy2,  p.  138. 


§  in 


DIFFUSE    HYPERTROPHY    IN    ADULTS. 


-Cases  Illustrative  of  the  Chief  Types  of  Diffuse  Hypertrophy 
in  Adults. 


85 


Before  entering  on  the  description  of  this  disease  in  general 
terms,  it  will  be  advantageous  to  relate  some  of  the  most  notable 
examples  of  each  of  its  chief  types. 

A. — Most  cases  arise  about  the  time  of  puberty,  when  the 
breasts  are  in  the  transition  state.     In  the    resulting   enlarge- 


FiG.   16. — -Hypertrophy  of  both  breasts  in  a  nun  {Manec). 

ments  stroma  structures  predominate,  chiefly  of  the  fibrous 
kind,  although  a  considerable  quantity  of  glandular  tissue  is 
always  present  as  well. 

Case  I. — Manec's'^  patient  was  a  nun  aged  17,  whose  breasts  presented 
as  two  enormous  pendent,  pedunculated  masses  covering  the  whole  of  the 
front  of  the  abdomen,  as  far  down  as  the  pubes  (Fig.  16).  The  greatest  cir- 
cumference of  the  left  was  75  centimetres  ;  and  of  the  right  72  centimetres. 


Gaz.  des  Hop.,  No.  18,  1859,  p.  45. 


86  HYPERTROPHY. 

The  left  was  estimated  to  weigh  7  kilogrammes,  and  the  right  6|.  The 
skin  was  not  obviously  altered,  but  the  galactophorous  ducts  were  enor- 
mously dilated.  By  successive  operations  both  breasts  were  ablated,  and 
the  patient  was  thus  cured. 

Case  II. — Crofford'^  reports  the  case  of  a  girl,  aged  15,  who  commenced 
to  menstruate  about  a  year  previously.  Before  this,  her  mamms  were 
perfectly  normal.  Shortly  after  the  establishment  of  the  catamenia,  she 
noticed  that  her  breasts  had  become  unusually  large,  and  the  deformity 
rapidly  increased.  On  examination  both  breasts  were  of  enormous  size. 
The  left  in  its  largest  circumference  measured  35^  inches  ;  the  right  32^ 
inches.  The  adjacent  lymph  glands  were  unaffected.  Compression  and 
all  other  available  means  having  failed  to  arrest  the  progress  of  the  disease, 
both  breasts  were  amputated  by  lateral  flaps,  the  left  being  removed  sixteen 
days  after  the  right.  When  last  heard  of  about  nine  months  after  the  second 
operation  she  was  in  good  health  ;  and  free  from  any  return  of  the  disease. 
The  weight  of  the  right  breast  after  removal  was  14,  and  of  the  left  11^  lbs. 
At  the  time  of  the  operations,  the  diseased  organs  were  noticed  to  be  very 
vascular.  The  subcutaneous  fatty  layer  over  each  breast  had  disappeared, 
being  replaced  by  the  rapidly  growing  diseased  organ.  On  section  each 
presented  a  pale  yellowish-white,  doughy,  nodulated  aspect,  with  vascular 
areas  here  and  there,  some  parts  being  quite  hard  and  quasi-fibrous,  while 
others  were  soft,  the  whole  exuding  a  juice  that  contained  granular  cells. 
On  Jiistological  examinaiion  the  bulk  of  the  growth  consisted  of  fibrous 
tissue,  devoid  of  fat,  with  glandular  structures  sparsely  embedded  in  it — 
in  some  places  of  normal  appearance,  in  others  evidently  degenerating. 
Some  of  these  glandular  structures  were  filled  with  hyperplastic  cell  elements. 
Every  part  of  the  growth  was  pervaded  by  fibrous  tissue,  containing  but 
few  nuclei,  but  numerous  large  lymph  channels.  Even  with  osmic  acid  no 
fat  could  be  detected  in  this  stroma.  Near  the  base  of  one  of  the  enlarged 
organs  was  a  circumscribed  fibro-adenomatous  nodule  the  size  of  a  walnut. 

Case  III. — In  a  case  by  Labbe,'^  the  patient  was  a  well  formed  and 
healthy  looking  girl,  aged  14.  Both  breasts  were  exceedingly  hypertrophied, 
and  by  their  weight  they  caused  her  great  inconvenience.  Both  were 
amputated  :  after  removal  the  left  weighed  nearly  9  lbs.  and  the  right  nearly 
8  lbs.  The  disease  was  of  eight  months'  duration.  Menstruation  began  at 
12.  Histological  exainination  showed  that  the  increase  in  size  was  chiefly 
due  to  overgrowth  of  the  fibrous  tissue  of  the  organ. 

Case  IV. — Le  Double''  has  recorded  the  case  of  a  healthy-looking  servant 
girl,  aged  15,  living  in  Paris,  but  not  a  virgin.  Menstruation  began  at  the 
age  of  14,  and  continued  normally  for  six  months,  when  it  suddenly  ceased 
without  any  known  cause.  Almost  at  the  same  time  both  breasts  began  to 
enlarge.  A  month  later  the  catamenia  reappeared,  and  subsequently  con- 
tinued regularly,  although  excessive  in  quantity.  The  breasts,  however, 
continued  to  enlarge.     When  she  was  first  seen  by  Le  Double,  six  months 


'•■'  American  yotirnal  of  Obstetrical  Science,  vol.  xxiv.,  1891,  p.  695. 
'*  Bull.  Acad,  de  Med.,  28  juillet,  1891. 
'■•  BtilLde  la  Soc.  Anat.,  1875,  I.  x.,  p.  185. 


DIFFUSE    HYPERTROriiV    IN    ADULTS.  ^t'J 

after  the  onset  of  the  disease,  both  breasts  were  of  great  size  and  pendulous, 
the  right  being  the  larger.  They  felt  firm,  elastic  and  lobulated.  The  nipple 
was  flattened  and  the  areola  distended.  The  skin  was  marbled  with  large 
veins,  and  that  over  the  lower  part  of  the  right  breast  was  congested.  There 
was  no  pain,  but  much  trouble  was  experienced  from  the  great  size  and  weight 
of  the  hypertrophied  parts,  which  made  walking  and  breathing  difficult.  She 
was  treated  by  the  internal  administration  of  twenty  drops  of  tincture  of 
iodine  daily,  and  subsequently  compression  by  bandaging  was  tried.  As 
there  was  no  obvious  improvement  after  some  months  of  this  treatment,  and 
as  the  patient's  general  health  was  failing,  it  was  decided  to  amputate  the 
right  breast.  This  was  accordingly  done — the  operation  being  commenced 
with  the  galvano-cautery  and  completed  with  the  bistoury.  The  wound 
healed  rapidly  ;  the  general  health  improved,  and  soon  afterwards  the  left 
breast  diminished  m^arkedly  in  size.  The  part  removed  weighed  1,987 
grammes  (4"3  lbs.).  On  examination  after  removal  the  overlying  skin  was 
normal,  and  glided  freely  over  the  subjacent  fatty  layer.  The  galacto- 
phorous  ducts  were  dilated.  Section  showed  a  lobulated  structure  of 
varied  aspect.  Most  of  the  lobes  were  about  the  size  of  walnuts.  In 
some  parts  were  whitish  areas,  studded  with  small,  soft,  yellowish  granu- 
lar areas,  which  were  hypertrophied  glandular  cul-de-sacs.  In  other  parts, 
especially  at  the  periphery,  there  was  a  dense  fibrous  structure  of  nacreous 
aspect.  Between  the  lobes  were  several  small  cystic  cavities  containing 
serous  fluid.  Fatty  tissue  was  found  chiefly  under  the  skin,  and  more 
sparingly  between  the  lobes  ;  its  total  amount  was  inconsiderable.  Micro- 
scopic exainination  of  sections  of  the  lobulated  masses  showed  them  to  be 
composed  mainly  of  white  fibrous  tissue,  infiltrated  here  and  there  with 
small  round  cells.  A  considerable  quantity  of  glandular  structures — acini 
and  ducts — were  embedded  in  this  stroma  ;  these  were  more  abundant  in 
some  parts  than  in  others,  and  they  were  filled  with  cubical  epithelial  cells. 
The  overgrowth  was  thus  composed  of  both  connective  and  epithelial 
elements,  the  former  preponderating.  A  considerable  number  of  blood 
vessels  were  met  with  in  the  stroma. 

Case  V. — Desenne's  patient"^  was  a  healthy-looking  mulattress  of 
Mauritius,  aged  15,  an  illegitimate  child  of  Creole-Indian  extraction.  The 
left  breast  began  to  enlarge  one  year  previously,  after  an  attack  of  malarial 
fever,  in  the  course  of  which  the  part  became  swollen  and  painful.  Four 
months  later  the  right  breast  also  increased  in  size,  and  an  abscess  formed 
in  its  lower  part.  The  catamenia  were  entirely  absent,  and  no  sign  of  them 
had  ever  appeared.  She  admitted  having  first  had  sexual  intercourse  at  the 
age  of  1 1,  and  of  having  continued  it  almost  every  day  for  the  next  two  and 
a-half  years.  During  this  time  the  mammae  were  inconspicuous,  and  there 
were  none  of  the  other  signs  of  puberty.  It  was  only  a  few  months  before 
the  onset  of  the  present  disease,  that  the  breasts  began  to  develop,  and  that 
hairs  appeared  on  the  pubes.  When  she  came  under  observation,  one  year 
after  the  onset  of  the  disease,  both  breasts  were  large  and  pendulous,  reach- 


"■  Le  Progres  Med.,  1886,  p.  492. 


88  HYPERTROPHY. 

ing  below  the  level  of  the  umbilicus — the  left  being  the  larger.  The  left 
breast  was  now  amputated,  and  the  patient  soon  recovered  from  the  opera- 
tion. Two  and  a-half  months  later  she  was  seen  again,  when  it  was  found 
that  in  the  interval  the  light  breast  had  considerably  enlarged.  About  this 
time  the  catamenia  appeared  for  the  first  time,  and  subsequently  recurred 
regularly.  Shortly  afterwards  the  right  breast  was  amputated,  and,  as  after 
the  previous  operation,  she  soon  made  a  good  recovery.  She  was  last 
heard  of  three  years  later,  when  she  had  been  safely  confined  of  a  healthy 
male  child.  The  left  breast  after  removal  weighed  nearly  4^  lbs.  On 
section  it  consisted  mainly  of  dense,  lardaceous  tissue,  containing  a  few 
cysts  with  mucoid  contents.  Microscopical  examiiiation  showed  numerous 
hypertrophied  glandular  acini  distended  with  mucoid  fluid,  embedded  in 
white  fibrous  tissue,  whose  cells  were  in  active  proliferation. 

Case  VI. — In  Benoit  and  Monteil's^'  case,  the  disease  began  at  14^. 
At  16  both  mammje  were  of  great  size,  and  remained  so  until  24,  when  she 
married.  After  marriage  they  diminished  ;  and  the  retrogression  became 
still  more  marked  after  pregnancy.     In  this  respect  the  case  is  unique. 

Case  VII. — A  typical  specimen  of  this  kind  of  hypertrophy  may  be  seen 
in  the  Museum  of  the  Royal  College  of  Surgeons  of  London  (No.  4739  of 
the  Path.  Series).  It  was  removed  by  Fergusson,  from  a  single  woman, 
aged  19,  both  of  whose  breasts  had  been  enlarging  for  a  year  and  a  half. 
The  hypertrophied  part  after  removal  measured  a  foot  in  diameter,  and  its 
weight  was  13  lbs.  Its  structure  resembled  that  of  the  normal  mamma 
except  for  the  great  increase  in  size.  The  blood  vessels  were  enlarged. 
Microscopic  examination  showed  overgrowth  of  the  glandular  parenchyma, 
as  well  as  of  the  fibro-fatty  structures.  The  other  breast  was  amputated 
three  months  later. 

Similar  cases  have  been  recorded  hy  Humbert, ^^  Kaufmann,^^ 
Marjolin,^'^  MacSwiney,^^  Grahs,^^  Birkett,^^  Malgaigne,^^  Finger- 
huth,25  Hey,2«  Aitken,^^    and    others. 

As  a  good  example  of  mammary  hypertrophy  in  which 
the  stress  of  the  disease  fell  on  the  fatty  tissue,  Robert  and 
Amussat's  ^**  case  may  be  cited. 


"  MontpelUer  Med.,  t.  xxxviii.,  1877,  p.  481. 

'*  Gaz.  des  Hop.,   1885,  p.  433. 

'»  Corr.  Bl.  f.  Schiveiz,  /lerzie,  No.  13,  1882. 

2"  Gaz  des  Hop.,  1868,  No.  131,  p.  519. 

*'  Dublin  Quarterly  youriial  0/ il/ed.  Sci.,  vol.  xlviii..  1869,  p. -500. 

'^-  .Sclimidi's  Yahrbucher,  Bd.  11 8,  1863,  S.  44. 

^  "  Diseases  of  the  Breast,"  1850,  p.  108. 

''^'  Gaz.  des  Hop.,  1844,  p.  599. 

-'  Zeilschrifl  f.  die  ,qesa!n?iite  A'ledicin,  1837. 

^"  "  Practical  Observations  in  Surgery,"  1810,  p.  500. 

■-'  Mfd.  Times  and  Gaz.,  vol.  ii.,  1878,  p.  608;    also  vol.  1.,  1857,  p.  360. 

'■"  V Union  Med.,  185 1,  p.  219. 


DIFFUSE    HYPERTROPHY    IN    ADULTS.  89 

Case  VIII. — The  patient  was  a  healthy  looking  woman,  in  whom  the 
catamenia  first  appeared  at  iS.  Four  months  later  they  ceased  without  any 
known  cause.  The  breasts,  till  then  small,  became  painful  and  swollen,  the 
left  first  and  then  the  right.  In  the  course  of  a  year  they  attained  a  large 
size  and  became  pendulous.  When  seen  two  years  later,  she  was  emaciated, 
but  otherwise  in  fairly  good  health. 

The  front  of  the  abdomen  was  entirely  covered  by  her  immense  breasts, 
which  reached  to  the  knees.  On  account  of  their  great  weight  she  had 
been  obliged  to  maintain  the  recumbent  position  for  the  last  two  years. 
The  left  breast  was  now  amputated.  Its  blood  vessels  were  very  large  ; 
in  the  course  of  the  operation  she  lost  about  two  pints  of  blood  ;  however, 
she  soon  recovered.  Twenty-six  days  after  this  operation  the  right  breast 
was  removed.  Again  she  made  a  speedy  recovery.  Two  months  later  her 
general  condition  had  much  improved.  After  removal  the  left  breast 
weighed  2°^  lbs.,  and  the  right  20^.  The  patient's  weight  after  their 
removal  was  loi  lbs.  ;  the  weight  of  the  two  tumours  was  therefore  more 
than  half  that  of  the  whole  body.  The  enlarged  breasts  consisted  chiefly 
of  fatty  tissue,  embedded  in  which  were  excessively  hypertrophied  glandular 
lobules.  It  is  not  improbable  that  this  may  really  have  been  an  instance 
of  diffuse  lipoma  ;  at  any  rate  in  hypertrophy  such  great  overgrowth  of  the 
fatty  tissue  is  very  unusual.  A.  Cooper-^  has  recorded  a  somewhat  similar 
case. 

The  three  following  cases  illustrate  the  more  acute  form  of 
this  type  of  hypertrophy. 

Case  IX. — A  healthy-looking  servant  girl,  aged  16,  vz'rgo  httacta^  came 
under  Billroth's^"  observation,  with  both  breasts  immensely  hypertrophied 
so  that  they  reached  below  the  umbilicus,  the  left  being  the  larger  (fig,  17). 
She  said  they  had  attained  this  great  size  in  the  course  of  two  and  a  half 
months.  Menstruation  began  at  the  age  of  15.  She  declined  operative 
treatment,  and  when  last  heard  of,  one  year  later,  the  breasts  were  said  to 
be  a  little  smaller. 

Case  X. — The  subject  of  the  disease  in  this  case  was  a  young  and  active 
negro  girl,  of  medium  size,  engaged  in  domestic  service  at  Philadelphia, 
U.S.^'  Changes  indicative  of  puberty  set  in  at  14  ;  but  she  menstruated 
only  once,  and  the  discharge  was  very  scanty.  About  this  time  the  left 
breast  began  to  surpass  its  proper  size  ;  and  soon  afterwards  the  right. 
Subsequently  both  increased  rapidly.  At  the  age  of  16,  she  was  admitted 
into  hospital,  on  account  of  a  large  slough  having  formed  at  the  dependent 
part  of  the  left  breast,  after  a  contusion.  Both  breasts  were  pendulous  and 
of  great  size,  the  left  being  the  larger  ;  they  reached  below  the  level  of  the 
umbilicus.  The  nipples  were  embedded  ;  and  the  left  breast  was  very 
painful.     The  general  health  was  greatly  impaired  ;  and  there  was  fever  of 


-■'  "  Diseases  of  the  Breast,"  1828,  p.  66. 

^"  Krankheiten  der  Brustdrii.sen.  Deutsche  Chirurgie,  Lief  41,  18S0,  S.  69. 

^'  Huston,  Am.  Journal  Med.  Sci.,  No.  xxviii.,  1834,  p.  374. 


90 


HYPERTROPHY. 


t  he  hectic  type.     In  the  course  of  a  few  days,  unmistakable  signs  of  gan- 
grene of  the  whole  of  the  left  breast  set  in,  together  with  delirium  and 


Fio.    17.  —  Hypertrophy  of  both  breasts  in  a  virgin,  aged  16  {Billroth). 


exhaustion.     She  died  thus  on  the  eighth  day  after  admission.     After  death 
the  right  breast  weighed   12  lbs.  ;  and  the  left  20.     On  examination  of  the 


DIFFUSE    HYPERTROPHY    IN    ADULTS.  QI 

right  breast  after  removal,  it  was  found  that  the  disease  consisted  of  simple 
overgrowth  of  the  whole  organ  ;  in  which  the  adipose  and  fibrous  tissues, 
as  well  as  the  glandular  parenchyma,  had  participated.  The  ovaries  were 
diseased  and  larger  than  normal  ;  and  the  interior  of  the  body  of  the  uterus 
was  lined  with  a  layer  of  coagulable  lymph. 

Case  XI. — This  case^'  is  remarkable  for  the  suddenness  of  the  onset  of 
the  disease,  for  the  rapidity  of  its  progress,  and  for  the  colossal  size  attained 
by  the  breasts  ;  in  all  of  which  respects  it  is  unparalleled.  It  occurred  in 
the  person  of  a  short,  fair-complexioned  w^oman,  between  23  and  24  years 
of  age.  She  was  in  rather  poor  circumstances,  but  of  good  constitution, 
and  a  native  of  Plymouth.  On  July  3,  she  went  to  bed  in  her  usual  health 
and  slept  well.  "  In  the  morning  when  she  awakened  and  attempted  to 
turn  herself  in  bed,  she  was  not  able  to  do  so,  finding  her  breasts  so 
swelled."  For  six  months  before  the  onset  of  the  disease  she  had  suffered 
from  complete  suppression  of  the  catamenia.  When  she  first  came  under 
observation,  shortly  afterwards,  both  breasts  were  greatly  enlarged  ;  and  it 
was  estimated  that  the  left  breast,  which  was  the  larger,  weighed  25  lbs.  On 
this  account  she  was  obliged  to  keep  her  bed,  which  she  never  afterwards 
left.  During  the  ensuing  months,  the  breasts  increased  rapidly  in  size  ;  and 
then  ulcers  formed  at  their  lower  parts.  Loss  of  appetite  with  progressive 
emaciation  set  in  ;  and  she  died  of  exhaustion  on  October  21.  The  total 
duration  of  the  disease  was  thus  under  four  months.  After  death  the  left 
breast  was  removed,  when  it  was  found  to  weigh  64  lbs.  ;  the  right  breast 
was  estimated  to  weigh  40  lbs.  On  section,  the  structure  of  the  diseased 
part  resembled  that  of  the  normal  female  breast,  from  which  it  differed  only 
in  its  great  size. 

B. — The  five  following  cases  are  instances  of  the  disease 
arising  at  a  later  period  of  life,  unconnected  with  pregnancy, 
when  the  breasts  are  in  the  state  of  passive  maturity. 

Case  I. — An  unmarried  woman,  aged  41,  both  of  whose  breasts  had 
been  slowly  enlarging  for  eleven  years.^^  No  history  of  injury  or  other 
known  cause.  Her  aunt  died  of  cancer  of  the  breast.  Old  scarring  of 
both  sides  of  the  face  from  lupus.  Both  breasts  large,  pendulous  and  pain- 
ful. On  manipulation  they  felt  firm  and  nodular.  The  injection  of  arsenic 
and  elastic  compression  were  tried  ;  but  as  no  improvement  followed,  both 
breasts  were  amputated  at  one  operation.  The  patient  made  a  good  recovery. 
After  removal  the  breasts  weighed  27  and  22  oz.  respectively.  On  section 
they  presented  a  dense  fibroid  appearance. 

Case  II. — In  a  healthy-looking,  married  woman,  aged  43,  who  had 
always  menstruated  regularly.  The  left  breast  began  to  enlarge  a  year  ago, 
without  any  known  cause.     When  first  seen  by  Velpeau,^^  the  left  breast  was 


Durston,  W.,  Phil.  Trans.  R.  S.  Lond.,  vol.  iv. ,  1669,  p.  1047,  and  p.  1068. 
Boyd,  Univ.  Coll.  Hasp.  Rep.,  1881,  p.  40. 
"  Traite  des  Maladies  du  Sein,"  1854,  p.  239. 


92  HYPERTROPHY. 

very  voluminous,  heavy  and  pendent.  Its  superficial  veins  were  enlarged. 
The  whole  mamma  felt  bossy  and  of  variable  consistence.  She  was  the 
mother  of  two  children  ;  both  of  whom  she  had  suckled.  The  enlarged 
breast  was  amputated  ;  and  the  patient  was  quite  well  a  month  after  the 
operation.  On  examination  of  the  part  after  removal,  the  skin  was  thin  and 
non-adherent  ;  the  subcutaneous  fatty  layer  had  disappeared  ;  the  bulk  of 
the  tumour  was  made  up  of  a  lobulated  structure,  and  between  the  lobes 
was  loose  connective  tissue  ;  each  lobe  consisted  of  dense  fibrous  tissue 
in  which  was  embedded  softish  granular  material. 

On  microscopic  examination  of  sections  of  these  lobes  they  all  showed 
glandular  structures,  surrounded  by  white  fibrous  tissue. 

Case  III. —  Lihotzky^'  exhibited  before  the  Vienna  Obstetrical  Society  in 
February,  1892,  a  hypertrophied  breast  removed  from  a  single  woman,  aged 
26.  When  fresh  it  weighed  nearly  10  lbs.  There  was  uniform  increase  in 
the  interglandular  connective  tissue  with  development  of  glandular  acini  in 
abundance. 

Proctor,^'^  Burton  ^^  and  Demarquez  ^^  have  recorded  similar 
cases. 

Proctor's  patient  was  a  negress,  aged  40,  in  whom  the  disease  was 
of  twelve  years'  duration  ;  in  Burton's  case  the  progress  was  more  rapid, 
both  breasts  having  attained  great  size  in  the  course  of  less  than  a  year. 
The  woman  was  40  years  old,  and  the  disease  followed  the  removal  of 
an  ovary  and  tube  for  an  inflammatory  affection. 

C. — Many  cases  of  mammary  hypertrophy  arise  in  connec- 
tion with  pregnancy,  when  the  glandular  parenchyma  is  chiefly 
affected,  as  in  the  following  examples  : — 

Case  I. — Porter^"  gives  the  history  of  a  woman,  aged  y],  who  three 
years  previously  first  noticed  swelling  of  the  right  breast,  which  gradually 
increased.  Three  months  after  the  onset  of  this  enlargement,  the  left  breast 
also  increased  in  size.  They  steadily  attained  such  great  dimensions,  that  at 
last  she  was  hardly  alile  to  stand  ;  but  there  was  no  pain.  On  examination 
the  greatest  circumference  of  the  right  measured  38,  and  of  left  28  inches. 
The  overlying  skin  was  cedematous  and  thickened.  In  both  breasts 
numerous  hard  irregular  nodules  could  be  felt.  The  left  breast  was  first 
amputated,  and  three  weeks  afterwards  the  right.  She  soon  recovered  from 
the  last  operation,  but  before  long  she  developed  erysipelas  in  the  right 
mammary  region.  As  this  was  fading  away,  she  suddenly  aborted  of  a  six 
months'  foetus,  and  died  a  few  hours  afterwards  of  collapse.     Pregnancy 


^  Cent.  f.  Gyndk.,  No.  10,  1892. 

•*  British  Medical  Journal,  1883,  vol.  ii.,  p.  456. 

■''  Liverpool  Med.  Chir.  Journal,  Jan.,  1892,  p.  138. 

»'^  Gaz.  Med.  de  Paris,  1859,  p.  818. 

•*  Boston  .'\fed.  and  Suri;.  Journal,  March  3,  1892. 


DIFFUSE    HYPERTROPHY    IN    ADULTS.  93 

was  not  suspected  until  she  was  convalescent  from  the  second  operation. 
Histologically  examined,  the  predominant  structure  was  oedematous  fibrous 
tissue,  rich  in  cells,  embedded  in  which  were  acinous  and  tubular  glandular 
structures.     There  were  numerous  intra-canalicular  fibromatous  growths. 

Case  II. — An  anaemic  woman  ^^ — aged  26,  subject  to  amenorrhoea,  who 
married  at  21,  and  was  the  mother  of  five  children — noticed  that  during  her 
first  pregnancy  the  right  breast  became  unduly  enlarged  and  painful  ;  but 
after  accouchement  its  size  diminished,  although  it  never  regained  its 
normal  bulk.  During  each  of  the  four  succeeding  pregnancies,  these 
phenomena  were  repeated  ;  the  breast  after  each  confinement  being  left 
larger  than  before.  When  she  first  came  under  observation,  at  the  end  of 
her  fifth  pregnancy,  the  right  breast  reached  to  the  iliac  crest,  and  it  was 
estimated  to  weigh  20  lbs.  It  was  of  varying  consistence,  and  several  firm 
lobulated  masses  could  be  felt  in  it.  The  left  breast  was  normal,  and  gave 
a  plentiful  supply  of  milk  during  the  lactation  period  ;  but  none  was  ever 
secreted  by  the  right.     She  refused  operative  treatment. 

Case  III. — In  this  case^'  the  patient  was  a  domestic  servant  of  good 
physique,  who  when  19  years  old  first  noticed  marked  enlargement  of  both 
breasts.  During  the  next  two  years  and  a  half  they  continued  slowly  to 
increase,  without  causing  her  pain  or  any  other  special  inconvenience.  Her 
previous  health  had  been  good.  Menstruation  began  at  15,  and' continued 
regularly  until  she  was  21^  years  old,  when  it  suddenly  ceased.  From  this 
time  the  size  of  the  mammas  increased  with  great  rapidity,  and  she  was  soon 
unable  to  follow  her  avocation.  When  she  was  first  seen  by  Billroth  the 
disease  was  of  three  years'  duration.  Both  mammae  had  then  attained  a 
great  size,  reaching  to  the  navel  ;  and  the  patient  was  obliged  to  maintain 
the  recumbent  position  on  account  of  their  great  weight.  The  nipples 
were  effaced,  the  areola  enlarged,  and  the  skin  was  marbled  with  large 
veins.  On  examination  she  was  found  to  be  five  months  pregnant.  Com- 
pression with  elastic  bandages  was  resorted  to,  but  the  pressure  caused 
excoriations.  In  connection  with  these  erysipelas  set  in.  On  the  following 
day  abortion  took  place  ;  and  she  died,  collapsed,  the  day  after.  Exami- 
nation of  the  breasts  after  death  showed  diffuse  overgrowth  of  the  glan- 
dular and  connective  constituents  ;  and  each  organ  presented  numerous 
circumscribed,  lobulated,  fibro-adenomatous  masses,  which  contained 
colostrum-like  fluid,  as  also  did  their  ducts.  Microscopic  examinatio7i  of 
the  parenchymatous  new  formation,  showed  large,  closely  packed,  and 
irregularly  formed  acini,  with  comparatively  little  intervening  connective 
tissue.  The  appearance  presented  by  some  of  the  sections  somewhat 
resembled  glandular  carcinoma. 

Case  IV. — Both  breasts  of  a  healthy  woman,^-  aged  26,  began  to  enlarge 
shortly  after  the  rather  sudden  suppression  of  the  catamenia.  In  the  course 
of  five  months  they  attained  a  great  size,  and  became  tender  and  painful. 
Two  months  later  it  was  discovered  that  the  patient  was  in  an  advanced 


^°  Speth,  Aerztl.  Int.  BL,  Miinchen,  18S5,  Bd.  xxxii.,  S.  479,  501  and  559. 
*^  Billroth,  Die  Krank.  der  Brustdriisen,  Deutsche  Chir.,  Lief.  41,  r88o,  S.  7r. 

^-   Skuhersky  in  Weitenweber' s  neue  Beitrilge  z.  Ckir.,  1841,  S.  42. 


94  HYPERTROPHY. 

stage  of  pregnancy,  which  she  had  before  denied.  The  breasts  were  now 
larger  than  ever  ;  the  nipples  and  areolae  had  become  embedded  in  their 
mass  ;  and  the  superficial  veins  were  unduly  prominent.  The  general 
health  was  impaired.  About  two  months  later,  after  a  lingering  labour  of 
four  days,  she  was  delivered  at  term  of  a  pale,  emaciated  and  feeble  male 
child.  Soon  afterwards  the  mammae  diminished  rapidly,  and  the  general 
health  improved.  No  milk  was  ever  secreted.  Two  months  later  her 
health  was  quite  restored  ;  and  the  breasts  were  still  further  diminished 
in  size.  She  was  treated  with  iodine  internally,  and  iodide  of  potassium 
ointment  was  rubbed  into  the  breasts,  but  these  never  regained  their  proper 
size.  Some  months  later  she  was  able  to  resume  her  avocation  as  a 
domestic  servant,  and  menstruation  was  regularly  re-established.  More 
than  two  years  later,  she  again  came  under  observation,  with  cessation  of 
the  catamenia  of  four  months'  duration,  and  rapidly  progressing  enlarge- 
ment of  the  breasts.  Fresh  pregnancy  was  recognised.  As  this  went  on 
the  breasts  got  larger  and  lai-ger  until  they  reached  the  pubes,  when  on 
account  of  their  great  weight,  she  was  obliged  to  maintain  the  recumbent 
position.  At  term  she  was  delivered  of  a  well-formed,  still-born,  female 
child.  Each  breast  was  then  estimated  to  weigh  about  20  lbs.  No  milk 
was  secreted.  Shortly  after  the  confinement,  both  breasts  became  red, 
painful  and  cedematous  ;  large  vesicles  formed  over  their  lower  parts, 
followed  by  ulceration  and  gangrene.  At  the  same  time  fever  set  in,  with 
rapid  progressive  emaciation,  diarrhoea,  dyspnoea  and  cough.  She  died 
thus  of  exhaustion  on  the  fourteenth  day  after  her  confinement. 

At  the  necropsy,  twenty-four  hours  after  death,  there  was  extensive 
gangrene  of  both  breasts.  After  ablation  the  right  weighed  18  lbs.  ;  and  the 
left  19  lbs.  Both  were  very  oedematous,  and  contained  numerous  small 
cysts.  There  was  great  excess  of  the  interlobular  fibrous  tissue,  and  the 
galactophorous  ducts  were  dilated.  There  were  tubercular  lesions  of  both 
lungs. 

Case  V. — Lotzbeck  '•'  has  reported  a  case  of  unilateral  hypertrophy  that 
began  about  puberty.  During  the  second  pregnancy  the  breast  attained 
immense  size.  However  she  suckled  with  it,  as  with  the  other.  Subse- 
quently uncontrollable  galactorrhoea  set  in,  which  only  ceased  when  the 
breast  was  amputated.  This  is  one  of  the  very  few  cases  in  which  the 
lacteal  secretion  has  become  established  in  a  hypertrophied  breast. 

Case  VI. — The  following  case  by  Warren  "**  is  of  interest,  as 
in  it  the  fatty  envelope  of  the  gland  was  the  part  chiefly  involved. 

A  married  lady,  aged  28,  had  for  some  months  noticed  rapidly  increasing 
enlargement  of  her  left  breast.  On  examination  Warren  found  the  breast 
uniformly  enlarged  ;  the  skin  rather  red  and  hot,  but  otherwise  normal. 
The  axillary  glands  also  were  normal.  As  treatment  failed  to  avert  the 
progress    of    the  disease,  the   breast    was  amputated.       After  removal  it 

'"  Schmidt's   Yahrb.,  Bd.  cvi.,  1861,  S.  51. 

"  "Surgical  Observations  on  Tumours,"  Boston,  1837,  p.  228. 


PROGRESS,    ETIOLOGY    AND    TREATMENT. 


95 


weighed  8  lbs.     The  only  change  noticeable   was  overgrowth  of  its  fatty 
capsule.     Subsequently  the  other  breast  underwent  similar  enlargement. 

Other  cases  of  hypertrophy  associated  with  pregnancy  have 
been  recorded  by  Esterle,'^^  Rousseau,''^  Jordens,*^  Iverg,^^  &c. 

§    IV. Progress,  Etiology  and  Treatment. 

Although  in  favourable  cases  of  mammary  hypertrophy  the 
morbid  process  ceases  to  progress,  and  ends  by  leaving  nothing 
worse  than  deformity,  yet  in  many  instances  the  disease  runs 
a  most  dangerous  course.       It    usually  begins  insidiously  and 


Fig.   i8. — Hypertrophy  of  the  breasts.     Early  stage  [Birkett). 

progresses   gradually,  without    pain  or   tenderness.      The   first 

thing  to  attract  attention  is  the  increasing  size  of  the    breasts. 

At  this  early  stage  the  mammae  are  firm  and  elastic,  stand- 


«  Gaz.  Med.  de  Paris,  1858,  p.  678. 

*'  Revue  Med.  Chir.,  t.  iv.,  1856,  p.  596. 

"  HitfelamPs  Journal  d.  prackt.  Heilk.,  Berlin,  1801,  Bd.  xii.,  S.  28. 

^^  Ibid.,  Bd.  xiii. 


96  HYPERTROPHY. 

ing  well  out  from  the  chest  by  virtue  of  their  own  resiliency  like 
the  ideal  busts  of  the  great  sculptors  (fig.  18).  Later  on  they 
become  flaccid,  pendent  and  pedunculated.  The  nipples  are  not 
affected  by  the  disease,  except  that  they  tend  to  get  effaced 
from  distension  ;  the  areolai  enlarge  ;  and  both  are  sometimes 
embedded  in  the  growing  mass. 

Large  veins  become  visible  through  the  distended  integu- 
ment, which  usually  remains  otherwise  unaltered,  and  does 
not  adhere  to  the  subjacent  parts  as  in  diffuse  mastitis.  On 
manipulation,  the  diseased  part  feels  of  varied  consistence — 
bossy,  nodulated  masses  being  interspersed  with  soft  or  fluctua- 
ting areas.  Tenderness,  with  lancinating,  burning  or  aching 
pains  may  set  in  ;  but  usually  the  disease  is  painless. 

In  the  advanced  stage  the  breasts  sometimes  attain  colossal 
size,  reaching  as  low  as  the  patient's  thighs  or  knees  ;  and  their 
weight  may  be  such  as  to  equal  or  even  surpass  that  of  the 
whole  of  the  rest  of  the  body.  (Durston's  case,  &c.)  In 
instances  of  this  kind  progression  is  impossible ;  even  the  erect 
attitude  cannot  be  maintained  ;  bowed  down  by  the  weight 
of  their  enormous  breasts  such  patients  are  compelled  to 
maintain  the  recumbent  position.  Great  respiratory  embar- 
rassment often  arises  from  the  same  cause.  With  all  this  the 
adjacent  lymphatic  glands  remain  unaffected,  so  long  as  there 
are  no  inflammatory  complications.  These,  however,  are  very 
apt  to  arise.  They  usually  begin  with  redness  and  oedema 
at  the  lower  part  of  the  enlarged  breast ;  then  blebs  form, 
which  break  and  give  rise  to  ulcers  ;  and  these  may  be  suc- 
ceeded by  sloughing  or  even  by  gangrene  of  the  whole  breast. 
(Huston,  Skuhersky,  &c.) 

In  other  cases  inflammation  leads  to  the  formation  of 
abscesses  and  fistula.  Very  slight  injuries  suffice  to  bring 
about  such  lesions ;  or  they  may  arise  spontaneously.  In 
advanced  progressive  cases  the  general  health  becomes  im- 
paired, the  appetite  fails  ;  there  is  restlessness,  with  loss  of 
sleep,  weakness  and  emaciation  ;  hectic  symptoms  supervene, 
and    finally  death   from  exhaustion  may  ensue.     (Durston.^ 


PROGRESS,    ETIOLOGY    AND    TREATMENT.  97 

It  generally  requires  several  years  for  the  breasts  to  attain 
this  great  size  ;  but  sometimes  only  a  few  months.  As  a  rule 
the  most  acute  cases  are  those  that  arise  in  association  with 
pregnancy  ;  and  in  these  the  danger  to  the  life  of  the  patient 
is  the  greatest.     (Porter,  Speth,  Billroth,  &c.) 

The  children  of  such  women,  if  born  alive,  are  generally 
weak  and  stunted;  abortions  and  still-births  are  not  uncommon. 
Even  during  the  lactation  period  hypertrophied  breasts  seldom 
secrete  milk,  although  a  little  colostrum-like  fluid  may  generally 
be  expressed  from  them.  However,  in  Lotzbeck's  case  there  was 
galactorrhoea,  and  in  one  of  Billroth's  cases  the  diseased  part 
contained  milk.  When  unassociated  with  pregnancy,  the  pro- 
gress is  much  slower ;  and  life  is  seldom  endangered.  In  one 
case  the  disease  is  known  to  have  lasted  for  eighteen  years. 
It  usually  begins  in  both  breasts  at  about  the  same  time,  but 
not  unfrequently  only  one  is  at  first  involved,  and  subsequently 
the  other  becomes  affected,  or  the  disease  may  be  unilateral 
from  beginning  to  end.  When  both  are  affected,  the  left  almost 
invariably  surpasses  the  right  in  size  and  weight,  and  when 
only  one  is  involved,  it  is  generally  the  left. 

In  the  causation  of  this  disease,  it  seems  to  me  that  the  chief 
factors  are  certain  states  of  the  pelvic  genitalia,  which — through 
correlation  with  the  mammae — determine  in  the  latter  ex- 
aggerated formative  activity.  In  this  connection  the  influence 
of  age  is  a  striking  feature,  for  three-quarters  of  all  cases  begin 
between  the  years  of  14  and  30  (the  majority  being  under  20), 
that  is  to  say,  during  the  high  tide  of  sexual  activity,  when  the 
breasts  receive  from  the  sexual  organs  an  immense  stimulus. 
Only  very  rarely  does  the  disease  begin  after  40,  and  I  know 
of  only  one  instance  in  which  it  set  in  after  the  climacteric. 

Most  cases  arise  in  association  with  menstrual  deficiencies 
and  pregnancy.  The  particular  menstrual  defects  usually  met 
with  are  failure  of  the  function  to  be  established  at  its  proper 
time,  and  its  sudden  suppression  after  it  has  been  properly 
established.  These  two  conditions — amenorrhoea  and  mam- 
mary hypertrophy — are  frequently  associated.       The    influence 

7 


98  HYPERTROPHY. 

of  pregnancy  as  a  determining  cause  is  of  the  most  marked 
kind  {vide  the  foregoing  cases  under  section  B.)  ;  but  after 
delivery  the  swelling  generally  lessens,  although  the  normal 
size  of  the  part  is  never  regained.  Other  alleged  factors  in 
its  causation  are  repeated  manipulations  of  the  breast,  mas- 
turbation, excessive  coitus,  prolonged  suckling  and  trauma- 
tisms. In  three  cases  it  has  been  found  associated  with 
ovarian  disease,  but  in  two  there  appeared  to  be  no  causal 
connection  between  the  two  conditions. 

,  Heredity  has  been  noted  in  only  a  single  instance  (Rous- 
seau's case).  The  patient  was  one  of  several  sisters,  all  of  whom 
had  very  large  breasts,  and  of  these  one  became  the  subject  of 
hypertrophy,  under  the  influence  of  pregnancy.  Racial  and 
climatic  conditions  are  important  a^tiological  factors,  for  the 
disease  is  much  commoner  in  tropical  countries  than  in  Europe, 
and  most  cases  have  been  met  with  in  negresses,  Creoles  and 
mulattresses.  In  the  females  of  some  families,  and  of  some 
races  of  animals,  we  constantly  see  the  mammae  largely  de- 
veloped without  there  being  any  disease.  We  can  only  account 
for  this  by  reference  to  constitutional  peculiarity,  and  so  it  is 
with  some  cases  of  diffuse  hypertrophy. 

The  mammae  occasionally  become  enlarged  in  association 
with  uterine  hypertrophy  due  to  tumours  or  retained  menstrual 
secretion. 

Ribbcrt^^  has  shown  that  after  extirpation  of  one  mamma, 
its  fellow  becomes  hypertrophied,  and  this  in  adults  as  well  as 
in  the  young.  He  attributes  the  enlargement  mainly  to  in- 
creased development  of  the  glandular  structures,  the  result  of 
increased  blood  supply  owing  to  collateral  fluxion.  As  he 
points  out,  all  paired  organs  are  liable  to  this  vicarious  or  com- 
pensatory hypertrophy,  after  destruction  of  one  of  the  pair. 

It  must  be  admitted,  as  Herbert  Spencer  has  pointed  out, 
that  the  growth  and  development  of  every  part  of  the  body  is 


"    '  Ueber   die  compensatorische  Hypertrophic  iles  Geschlechtsdriisen,"  Arch, 
f.  path.  Anat.,  Bd.  cxx.,  1890,  S.  260. 


PROGRESS,    ETIOLOGY    AND    TREATMENT.  99 

regulated  by  a  certain  restraining  or  integrative  force,  which 
causes  its  cells  to  develop  in  a  regular  and  orderly  manner,  in 
accordance  with  the  specific  hereditary  tendency  of  the  whole. 
So  long  as  the  growing  cells  are  subject  to  this  normal  restrain- 
ing influence — which  has  nothing  to  do  with  nerves  or  blood 
vessels,  themselves  integrated  structures — the  proper  proportions 
of  the  body  are  maintained.  But  when  this  influence  is  weak- 
ened or  withdrawn,  the  potential  powers  of  the  cells  may  then 
become  actual,  and  various  structural  abnormalities  may  be 
produced.  It  appears  to  me  that  the  phenomena  of  mammary 
hypertrophy  are  ultimately  attributable  to  post-embryonic  de- 
velopmental aberrations  of  this  kind.  In  the  disease,  as  in  the 
physiological  overgrowths,  both  the  glandular  and  fibro-fatty 
structures  participate,  though  in  varying  proportional  degrees, 
according  to  the  developmental  stage  of  the  breast  at  the  time 
when  the  morbid  process  sets  in.  The  pathological  conditions 
met  with  in  the  various  types  of  hypertrophy  have  their 
counterparts  in  the  normal  physiological  processes.  In  both 
alike  the  essential  feature  is,  not  mere  enlargement  of  pre- 
existing elements,  but  excessive  new  formation  of  mammary 
tissues.  With  regard  to  the  pathological  anatomy  of  the 
disease,  a  sufficiently  full  description  has  already  been  given 
in  connection  with  the  foreoing  typical  cases. 

Probably  some  instances  of  acute  diffuse  malignant  disease 
of  the  breasts  are  an  outcome  of  this  form  of  hypertrophy  {e.g., 
cases  by  Aitken,  Klotz,  Billroth,  &c.). 

The  diagnosis  of  hypertrophy  of  the  breast  is  seldom  at- 
tended with  much  difficulty,  but  it  is  well  to  bear  in  mind  that 
large  cyst-adenomas,  cysto-sarcomas  and  lipomas,  occasionally 
present  appearances  resembling  it.  In  the  early  stage  it  may 
be  confounded  with  some  forms  of  chronic  diffuse  interstitial 
mastitis  with  multiple  cyst  formation,  but  in  the  latter  affection 
the  skin  generally  gets  adherent  and  thickened.  From  acute 
diffuse  malignant  disease,  it  may  be  distinguished  by  the  skin 
and  lymphatic  glands  being  unaffected. 

In  the  treatment  of  cases  unassociated  with  pregnancy,  atten- 
tion should  first  of  all  be  directed  to  the  menstrual  function  • 


lOO  HYPERTROPHY. 

and  endeavours  should  be  made  to  rectify  any  derangement. 
In  the  event  of  the  catamenia  being  retarded  or  suppressed, 
pil.  aloes  et  ferri  ok  pil.  aloes  et  myrrhce  may  be  prescribed  ;  and 
when  molimina  are  felt,  the  hot  pediluvium  with  mustard  at 
night  may  be  serviceable,  or  the  spinal  ice  bag  may  be  tried. 

All  forms  of  sexual  excitement  increase  the  morbid  tend- 
ency, and  must  therefore  be  avoided.  With  this  object  an- 
aphrodisiac  medicines,  bromides  and  unstimulating  regimen  are 
indicated,  together  with  saline  aperients.  Inasmuch  as  the 
influence  of  pregnancy  on  the  progress  of  the  disease  is  almost 
invariably  highly  prejudicial,  marriage  should  be  avoided. 
Iodine  and  its  compounds  have  been  more  frequently  employed 
than  any  other  remedy  both  externally  and  internally.  In  the 
early  stage  of  the  disease  compression  is  the  best  local  treat- 
ment. A  convenient  way  of  effecting  this  is  to  cover  the  breast 
with  a  thin  film  of  absorbent  wool,  and  then  to  paint  iodized 
collodion  ^^  freely  and  rapidly  over  it.  Compression  by  ban- 
daging, whether  with  ordinary  calico  bandages  or  elastic 
webbed  ones,  generally  proves  too  irksome  to  be  kept  up,  on 
account  of  its  interference  with  the  respiratory  movements, 
and  the  same  objection  applies  to  strapping.  To  overcome  this 
difficulty  special  forms  of  breast  compressors  have  been  de- 
vised, of  which  the  best  are  Arnott's  and  Duke's.*^^ 

When  the  disease  is  associated  with  pregnancy,  it  has  been 
recommended  by  Fingerhuth,  that  attempts  should  be  made  to 
excite  lactation  artificially  by  repeated  suction  of  the  nipples, 
&c.  I  am  not  aware  that  the  favourable  results  thus  obtained 
by  him  have  been  endorsed  by  others.  In  Monod's''^  case  it 
was   ineffective. 

If  after  trial  of  these  remedies,  the  disease  continues  to 
progress,  and  the  enlarged   part  becomes  troublesome  from  its 


'-"  Iodine,  jiot.  iod.  aa,  gr.  xx.  ;    collodion,  ^j. 

•'"  For  description  of  these  vide  Ch.  xxv. 

"  Bull  et  Mein.de  la  Soc.  de  Chir.,  1891,  p.  738. 


PARTIAL    HYPERTROPHY.  lOI 

size  and  weight,  amputation  must  be  resorted  to;  but  it  is 
desirable  to  avoid  proceeding  to  this  extremity  during  the  puer- 
peral state.  When  both  breasts  are  affected  the  larger  one 
should  be  amputated  first,  and  several  months  may  be  allowed 
to  elapse  before  repeating  the  operation  on  the  other ;  as  in 
some  cases  after  removal  of  one  breast,  its  fellow  has  diminished 
spontaneously.  The  operation  should  be  done  with  antiseptic 
precautions,  by  making  a  semilunar  incision  through  the  skin 
and  subcutaneous  fatty  tissue  on  each  side  of  the  base  of  the 
pedicle,  and  then  dividing  the  latter.  Care  must  be  taken  to 
avoid  unnecessary  loss  of  blood,  by  quickly  securing  the  severed 
vessels,  as  these  patients  being  weakened  by  the  disease  bear 
haemorrhage  badly.  To  this  end  an  efficient  plan  is  that  of 
transfixing  the  base  of  the  tumour  with  two  large  knitting 
needles,  and  behind  these  firmly  applying  a  temporary  elastic 
ligature  to  the  pedicle. 

Considering  the  great  size  often  attained  by  the  diseased 
part,  the  results  of  the  operation  are  very  good.  Thus  of 
twenty-two  such  amputations,  of  which  I  have  collected  notes, 
done  on  sixteen  patients,  there  was  only  one  death  (4'5  per 
cent.)  ;  this  patient  died  twenty-two  hours  after  the  operation 
of  collapse,  from  excessive  haemorrhage  during  the  proceeding. 

S    V. Partial  Hypertrophy. 

In  the  partial  form  of  mammary  hypertrophy,  the  disease 
may  be  limited  to  a  single  lobule,  or  several  may  be  affected. 
In  some  instances  large  areas  of  the  gland  are  thus  involved, 
indicating  transition  to  the  diffuse  form,  as  in  the  following 
cases. 

(i)  A  woman,  aged  33,  under  the  care  of  Richet,''^  with  a  slowly  pro- 
gressive sweUing  at  the  upper  and  outer  part  of  the  left  breast  of  five  years 
duration.     She  knew  of  no  injury  or  other  cause  for  it.     Her  only  child 


Gaz,  lies  Hop.,  1 881,  p.  322. 


I02  HYPERTROPHY. 

was  born  thirteen  years  ago,  when  both  breasts  were  normal  and  gave 
plenty  of  milk.  On  examination  the  left  breast  was  found  to  be  nearly  four 
times  its  proper  size,  and  its  surface  was  marbled  with  large  veins.  A  firm, 
nodular  swelling  occupied  its  outer  segment,  and  displaced  the  nipple  to- 
wards the  sternum  :  to  this  the  increased  size  of  the  part  was  due.  On 
palpation  the  swelling  was  composed  of  about  a  dozen  quasi-lobular  masses 
to  a  large  extent  separable  from  one  another.  There  was  no  pain  or  tender- 
ness. The  treatment  adopted  was  compression  by  elastic  bandage.  While 
under  treatment  she  had  several  floodings  due  to  uterine  fibroids. 

(2)  In  the  Hunterian  Museum^-'  is  a  specimen  of  a  right  mammary 
gland,  similarly  affected,  presented  by  T.  Smith.  It  was  removed  from 
a  young  lady,  aged  21.  who  had  noticed  increasing  enlargement  of  both 
breasts  for  three  years.  After  removal  it  weighed  3  lbs. ;  her  left  breast  was 
estimated  to  weigh  5  lbs.  The  enlargement  was  almost  entirely  due  to 
hypertrophy  of  the  lobules  of  the  axillary  and  inferior  segments  of  the  gland, 
which  formed  a  lobulated  mass  readily  detached  from  the  rest  of  the  organ. 
On  microscopical  cxaminatioji.,  this  consisted  of  white  fibrous  tissue,  studded 
with  glandular  structures,  the  former  being  in  excess. 

(3)  In  a  case  described  and  figured  by  Billroth''''  the  whole  breast  was 
affected  except  its  lower  segment.  The  diseased  part  was  composed  of 
nodulated  lobules  held  together  by  loose  fibro-fatty  tissue.  Histological 
examination  showed  that  the  lobules  consisted  of  dilated  acinous  and 
tubular  structures  embedded  in  fibro-cellular  tissue,  which  was  much  more 
abundant  than  in  the  normal  gland.  Billroth  was  unable  to  decide  whether 
the  parenchymatous  structures  were  of  neoplastic  formation  or  not.  He 
gives  no  clinical  details. 

In  most  cases  of  partial  hypertrophy  there  can  be  felt  in  the 
breast  one  or  more  firm,  circumscribed,  bossy,  mobile  nodules, 
which  are  obviously  connected  with  the  rest  of  the  gland. 
These  tumours  are  generally  of  irregularly  elongated  shape, 
radially  disposed,  and  they  usually  occupy  a  peripheral  position. 
Their  size  is  seldom  great,  varying  in  this  respect  from  an 
almond  to  a  date. 

They  never  contract  adhesions  with  the  adjacent  skin,  nor 
do  they  cause  retraction  of  the  nipple.  Their  development  is 
slow,  often  extending  over  many  years,  and  it  is  seldom  attended 
with  pain,  but  sometimes,  in  neurotic  individuals,  pain  is  a 
prominent  symptom  {iiodosiU's  ncvroiiiatiqiies  of  Velpeau). 
Serous  or  mucoid  discharge  from  the  nipple  is  not  uncommon. 


No  4739A,  Path.  Catalogue,  Appendix  ii..  i888,  p.  38. 
Deutsche  Chir.,  Lief.  41,  S.  77. 


PARTIAL    HYPERTROPHY.  IO3 

One  or  both  breasts  may  be  affected.  On  examination  of  such 
a  tumour  after  removal,  it  will  be  found  to  consist  of  a  dense 
whitish,  circumscribed  fibroid  structure,  in  which  small  yellowish 
spots  may  be  recognised  (glandular  elements).  In  connection 
with  the  latter  small  cysts  may  often  be  found.  By  means  of 
its  pedicle  the  ducts  of  the  tumour  are  in  direct  communication 
with  those  of  the  rest  of  the  gland. 

The  diagnosis  of  partial  hypertrophy  from  ordinary  fibro- 
adenoma, cold  abscess,  and  chronic  mastitis  often  presents  much 
difficulty.  The  chief  points  in  favour  of  partial  hypertrophy 
are,  the  presence  of  a  pedicle,  multiple  nodules,  and  freedom  of 
the  skin  from  adhesions. 

In  examples  of  this  disease  seen  by  me,  the  patients  have 
been  pale,  delicate  women,  in  whom  the  disease  has  appeared  to 
have  resulted  from  imperfect  involution  after  lactation.  With 
this  exception  it  is  commoner  in  young  adult,  unmarried 
women  in  feeble  health,  and  in  those  who  though  married  are 
sterile,  than  in  other  women.  It  is  often  associated  with  men- 
strual irregularities,  of  which  amenorrhoea  is  the  commonest, 
and  sometimes  with  uterine  fibroids  and  other  forms  of  chronic 
uterine  and  ovarian  disease. 

By  many  pathologists  cases  of  this  kind  are  ascribed  to 
chronic  mastitis,  but  the  evidence  of  inflammation  is  seldom 
appreciable. 

The  general  principles  of  treatment  here  are  the  same  as 
for  diffuse  hypertrophy.  Catamenial  irregularities  must  be  cor- 
rected. For  local  treatment  it  is  sufficient  in  slight  cases  to 
apply  emplast,  amnioniaci  cum  hydrargyro  or  eniplast.  belladonnce, 
so  as  to  exert  compression,  or,  as  I  prefer,  to  paint  the  breast 
with  iodized  collodion.  In  obstinate  cases  Arnott's  breast 
compressor  will  be  serviceable.  When  these  means  fail  the 
tumour  should  be  excised.  This  is  done  as  follows  :  the  tumour 
is  made  to  project  beneath  the  skin,  by  pinching  up  the  parts 
behind  it  with  the  forefinger  and  thumb  of  the  left  hand,  in 
such  a  way  that  its  long  axis  radiates  from  the  nipple,  an 
incision  is  then  made  through  the  overlying  skin,  &c.,  in  this 


I04  HYPERTROPHY. 

direction,  and  as  the  tumour  projects  it  is  transfixed  with  a 
sharp  hoop  and  pulled  upwards  until  by  a  little  dissection  it  is 
completely  separated.  This  operation  may  be  done  under 
cocaine,  by  first  painting  the  skin  with  lo  per  cent,  solution, 
and  then  injecting  a  few  minims  of  5  per  cent,  solution,  at 
various  points  of  the  periphery  of  the  tumour.  In  several  cases 
treated  in  this  way,  after  removal  of  one  tum.our  I  have  known 
others  to  form.  When  the  disease  is  extensive  cuneiform 
amputation  may  be  necessary. 

^     V  I . Gynaecomastia. 

Among  the  ancient  Greeks,  as  mentioned  by  Paul  of 
Egina,  undue  development  of  the  male  mammae  was  a  well 
recognised  affection.  At  the  present  time  it  seems  to  be  rare, 
for,  according  to  French  military  statistics  (Puech),  it  is  met 
with  in  the  proportion  of  only  one  in  13,000  conscripts. 

The  enlargement  of  gynaecomastia  differs  from  the  diffuse 
hypertrophy  of  females,  in  that  it  has  no  tendency  to  indefinite 
increase ;  having  attained  a  certain  size,  which  never  exceeds 
that  of  the  normal  female  mamma,  the  overgrowth  ceases  spon- 
taneously. At  any  rate,  I  am  not  aware  of  a  single  instance,  in 
the  records  of  modern  science,  in  which  this  limit  has  been 
surpassed.  In  ancient  literature,  however,  mention  is  made  by 
Petrequin  ■■^''  of  a  man  at  Pavia  with  mammae  18  inches  long,  and 
so  heavy  that  they  had  to  be  amputated. 

With  regard  to  the  histological  structure  of  the  enlarged 
organs,  from  such  scanty  data  as  science  has  hitherto  furnished, 
it  is  evident  that  they  present  great  variations  in  accordance 
with  the  age  of  the  individual  bearing  them.  In  old  persons, 
as  pointed  out  by  Griibcr  ''^  and  others,  the  enlargement  con- 
sists almost  entirely  of  fatty  tissue.     In   adults  Baillct  •'■'  and 


*'  Anai.  Med.  Chit:,  p.  231. 

5H  <«  Uber  die  Gyncecomastie,"  Man.  dc  PAcad.  des  Sci.   de  St.  Peterslniy^,  Jlh 
ser.,  t.  X.,  1866. 

'*  Bull,  de  la  Soc.  Anal.,  1890,  \).  532. 


(;VN.ECOMASTIA.  IO5 

Remy,™  have  found  that  it  was  mainly  due  to  increase  of  the 
fibrous  stroma,  in  which  a  few  glandular  ciil-de-sacs  were  em- 
bedded. On  the  other  hand,  De  Sinety^^  reports  having  ex- 
amined a  specimen  in  which  the  galactophoroUs  ducts  were  as 
well  developed  as  in  a  puerperal  woman,  and  lined  by  two  layers 
of  cylindrical  epithelium.  In  this  instance  the  glandular  cul-de- 
sacs  contained  fatty  globules,  and  there  were  well  developed 
acini,  lined  by  a  single  layer  of  cubical  epithelium.  The  latter 
structures,  however,  were  not  very  numerous.  A  considerable 
quantity  of  fatty  tissue  was  contained  in  the  stroma.  In  two 
cases  Gaillet  ^^  also  found  an  abundance  of  well  formed  glan- 
dular structures.  Thus  may  be  explained  the  occasional  secre- 
tion of  lactescent  fluid,  8z:c.,  by  these  hypertrophied  mammae. 

The  chief  interest  in  this  affection  centres  in  its  etiology.  It 
was  formerly  believed  that  gynaecomastism  invariably  implied 
testicular  atrophy,  loss  of  virility,  and  the  cachet  of  femininism. 
This  ancient  opinion,  although  not  without  some  foundation, 
can  no  longer  be  maintained;  for  it  is  now  known  that  gynae- 
comastism often  co-exists  with  absolute  integrity  of  the  sexual 
organs,  with  unimpaired  virility  and  without  any  of  the  charac- 
teristics of  femininism.  In  accordance  with  the  foregoing 
two  types  of  gynecomastism    may   be   discriminated. 

A. — In  the  first  the  sexual  organs  are  well  developed  and 
function  normally,  and  all  the  attributes  and  appearances  of 
virility  are  usually  present.  Cases  of  this  kind  are  probably 
due  to  reversion  to  the  condition  prevalent,  when  the  males 
aided  the  females  in  suckling  their  young.  Although  such 
breasts  usually  yield  no  secretion,  yet  they  have  occasionally 
been  known  to  secrete  colostrum-like  fluid  and  even  true  milk. 

Hunter"''  refers  to  the  case  of  a  gyna?comast,  aged  50,  whose  breasts 
gave  such  an  abundant  supply  of  milk,  that  he  shared  equally  with  his  wife 
in  suckling  their  eight  children. 

«°  Thhede  Paris,  1880. 

«'  Traite  de  Gyu.,  1884,  p.  953. 

•^^  C.  R.  de  la  Soc.  de  Biol.,  fev.,  1850. 

^^  "  Essays  and  Observalions,"  by  Owen,  vol.  i.,  p.  238. 


io6 


HYPERTROPHY. 


Even  in  the  absence  of  obvious  gynsecomastism,  it  appears 
that  repeated  suction  may  sometimes  determine  enlargement  of 
the  gland,  secretion  of  colostrum-like  fluid,  and  even  of  true 
milk,  as  in  cases  reported  by  Robert  ^^  and  Humbolt.*'^  Similar 
instances  have  been  observed  in  various  male  animals,  e.g.,  goat, 
dog,  ox,  cat,  hare,  &c. 


P'iG.    19.  —  Hypertrophy  of  the  right  breast  in  a  seaman  aged  21  {Morgan), 


Aristotle  refers  to  the  yield  of  milk  by  male  goats.  An  instance  of  this 
has  been  published  by  Blumenbach  ""^  in  which  the  animal  had  to  be  milked 
every  other  day  for  a  year.  I.  G.  St.  Hilaire*^'  kept  for  many  years  in  the 
Jardin-des-Plantes  at  Paris,  a  large-uddered  he-goat  that  freely  gave  milk. 

Most  hypertrophies   of  this    kind   arise    at   about    puberty, 
owing  to  the  formative  processes  natural  to  the  male  breasts  at 


**  Phil.  Trans.,  Lond.,  No.  461,  p.  813,  "  On  a  man  who  gave  suck  lo  a  child." 

'*^  "  Travels  in  Equinoxial  Regions,"  &c. 

"'  Coinp.  Anal.,  1827,  p.  365. 

*'  "  Sur  un  bouc  lactifere,"  C.  R.  de  r.-lcad.  dcs  ScL,  1845  ^'^^  1852,  p.  386. 


GYN/ECOMASTIA.  I O/ 

this  period,  instead  of  being  arrested  as  usual  after  a  short  time, 
continuing  to  progress,  as  in  the  normal  female  development. 
There  are,  however,  on  record  a  considerable  number  of  cases 
in  which  the  affection  has  originated  at  much  earlier  periods. 
In  the  cases  seen  by  me  both  breasts  have  been  enlarged  ;  but 
the  majority  of  the  recorded  cases  have  been  unilateral,  the  left 
breast  being  the  one  usually  affected. 

Subjoined  are  abstracts  of  some  illustrative  cases  : — 

(i)  In  the  person  of  an  ordinary  seaman,  aged  21,  Morgan''*'  found  the 
right  breast,  in  size  and  configuration,  just  like  that  of  a  well  developed, 
adult  female  (fig.  19).  The  left  breast  was  normal.  The  enlargement 
began  when  he  was  16^  years  old,  and  gradually  increased  to  its  present 
size.  No  secretion  had  ever  escaped  from  the  nipple.  The  man  was  in 
other  respects  well  formed,  his  testes  and  genitalia  being  normal.  For 
his  age  he  was  of  rather  youthful  and  effeminate  appearance,  and  he  had  no 
facial  hair. 

(2)  In  a  man,  aged  about  25,  Foot"'-'  found  both  breasts  as  large  as  those 
of  the  adult  virgin  female.  From  the  nipple  of  one  of  them,  thin  serous 
discharge  occasionally  escaped.  He  was  otherwise  well  developed,  with 
plenty  of  facial  hair,  and  presented  nothing  feminine  in  his  appearance  or 
disposition. 

(3)  In  another  case  by  the  same  author,  the  left  mamma  of  a  boy,  14 
years  old,  exactly  resembled  that  of  a  pubescent  female.  It  was  conical, 
dependent,  and  felt  of  firm  glandular  consistence.  He  was  in  other  respects 
normally  developed. 

(4)  In  a  soldier  seen  by  Tufnell'"  the  left  breast  in  form  and  size  was 
like  that  of  the  female  at  puberty.  It  began  to  be  large  at  12.  The  male 
secondary  sexual  characters  were  well  developed. 

(5)  Montgomery"  mentions  the  case  of  a  man,  aged  45,  with  well- 
developed  genitalia,  who  had  mamm^  like  those  of  an  adult  woman.  He 
never  married,  and  died  of  phthisis. 

Similar   cases    have   been    reported    by    Schnitt,''^    Peters,''^ 
Hunter,^^  and  others. 

As  instances  of  the  onset  of  the  affection  prior  to  puberty  in 


"^  Lancet,  vol.  ii.,  1875,  P-  1^1- 

''^  Dublm  Journal  of  Med.  Sci.,  vol.  xli.,  p.  417. 

'"  Ibid.,  vol.  xix.,  p.  230. 

"  "  Signs  and  Symptoms  of  Pregnancy,"  p.  125. 

'-  Rec.  de  Mem.  de  Med.,  cr'c,  Milit.,  Paris,  1881,  3  ser.,  t.  xxxvii.,  p.  690. 

"  N.  Y.  Med.  Times,  1863,  p.  196. 

'*  Op.  cit. 


I08  HYPERTROPHY. 

young  boys,  children,  and  infantSj  the  following  rare  cases  are 
noteworthy- 

(i)  A  young  man,  aged  22,  was  exhibited  at  the  Socicte  de  Chir.,  of  Paris, 
by  Labbe,'-'  in  1870,  whose  right  breast  was  then  just  like  that  of  a  well- 
developed  adult  female.  At  birth  the  part  was  unduly  large  ;  and  by  the 
time  he  was  5  years  old,  it  had  attained  a  considerable  size.  In  the  course 
of  the  next  few  years  it  increased  to  the  size  of  a  fowl's  egg.  With  the 
advent  of  puberty,  at  the  age  of  15,  its  maximum  dimensions  were  attained. 
When  about  12  years  old,  a  yellowish  discharge  was  noticed  from  the  nipple, 
which  continued  until  17.  The  other  mamma  was  normal.  His  genitalia 
were  well  developed. 

(2)  In  a  case  cited  by  Olphan,^*^  both  breasts  began  to  enlarge  in  a  boy 
only  4  years  old. 

(3)  Krieger'^  met  with  an  instance  in  an  otherwise  healthy  and  well- 
developed  lad  only  7  years  old.  He  had  noticed  swelling  of  the  breasts 
and  fluid  discharge  from  the  nipples  for  some  time  previously.  When  first 
seen  his  mammas  were  like  those  of  a  well-developed  female  at  puberty. 
His  skin  was  thin  and  delicate,  and  devoid  of  hairs.  In  both  breasts 
several  small  hard  nodules  could  be  felt.  On  pressing  the  enlarged  organs, 
milky  fluid  escaped  from  the  nipples,  which  were  seldom  free  from  some 
discharge.  This  fluid  was  alkaline  in  reaction,  and  contained  colostrum, 
granular,  and  large  epithelial  cells  in  fatty  degeneration. 

(4)  Belcher's  patient'**  was  a  delicate  looking  boy,  12  years  old,  whose 
left  breast  had  been  gradually  enlarging,  without  pain  or  tenderness,  for 
five  months,  Its  size  then  equalled  that  of  the  female  breast  at  puberty. 
The  right  breast  was  normal,  and  so  were  the  external  genitals.  In  answer 
to  a  letter  of  inquiry,  Dr.  Belcher  has  kindly  informed  me  that  the  boy, 
who  then  was  132  years  old,  presented  no  signs  of  puberty,  and  was  back- 
ward in  sexual  development.  The  testes  and  penis  were  of  norma!  size, 
but  there  were  no  hairs  on  the  face,  nor  on  the  pubes.  The  left  breast  had 
enlarged  a  little  during  the  last  year,  but  the  right  still  remained  normal. 

A  somewhat  similar  case  came  under  observation  at  the 
London  Hospital  in  i86o.'^'-' 

(5)  The  patient  was  a  delicate-looking  boy,  13  years  old,  whose  right 
breast  was  hypertrophied  to  the  size  of  his  fist. 

The  enlargement  began,  without  any  known  cause,  six  months  previously. 
The  left  breast  was  normal.  He  looked  younger  than  his  age,  and  mani- 
fested no  signs  of  puberty. 


"  Gaz.  lies  H6p.,  1S70,  p.  46. 

'*  These  de  Paris,  1880,  "  Sur  la  Gynecuniaslie." 

"  London  Med.  AV(.,  1879,  p.  404. 

"  Brit.  Med.  Journal,  1890,  vul.  i,  p.  364. 

'"  Medical  Times  and  Gaz.,  i860,  vol.  i.,  p.  11. 


GYNTIiCOMASTIA.  [O9 

It  is  most  exceptional  for  congenital  malformations,  other 
than  those  of  the  sexual  organs,  to  be  associated  with  gyna^co- 
mastism ;  but  in  a  case  reported  by  Wagner,^''  hypertrophy  of 
the  right  breast  co-existed  with  hypertrophy  of  the  right  upper 
extremity,  and  of  the  hand  and  finger. 

Very  few  instances  of  disease  of  the  hypertrophied  mamma 
have  been  recorded. 

(i)  Bryant'"  has  seen  a  gyncccomast,  aged  45,  in  whose  breast  a  fibro- 
adenoma had  developed. 

(2)  In  a  boy,  aged  16,  whose  left  breast  was  hypertrophied,  Foot^-  found 
a  cystic  tumour,  the  size  of  a  gooseberry,  at  the  base  of  the  nipple,  super- 
ficial to  the  hypertrophied  gland.  The  tumour  was  of  one  year's  duration. 
He  was  otherwise  well  formed  and  healthy. 

(3)  I  have  had  under  my  care  a  stout,  gouty  clergyman,  aged  about  50, 
both  of  whose  breasts  had  been  hypertrophied  since  youth,  with  painful 
nodular  induration  of  the  right  breast,  which  I  attributed  to  subacute  gouty 
mastitis.  Under  appropriate  treatment  the  pain  and  nodular  thickening 
disappeared.  A  few  years  previously  similar  nodular  induration  had  been 
dissected  out  of  his  left  breast,  under  the  belief  that  it  was  a  tumour.  He 
was  the  father  of  several  children,  and  the  facial  hair  was  moderately  ■ 
developed. 

In  the  preceding  chapter  (p.  52)  I  have  related  an  instance 
in  which  gynaecomastism  was  associated  with  supernumerary 
mammary  structures,  and  epithelioma  of  the  lower  lip. 

B. — The  second  type  of  gynaecomastism  is  invariably  asso- 
ciated with  some  morbid  testicular  condition  interfering-  with 
their  integrity  ;  consequently,  loss  of  virility  and  of  the  secondary 
male  characters  usually  go  with  the  mammary  deformity.  The 
morbid  conditions  referred  to  are  of  very  variable  nature ;  but 
they  may,  for  the  most  part,  be  grouped  under  one  or  other  of 
the  following  heads  : — 

(i)  Congenital  malformations  of  the  sexual  organs,  with 
defective  testicular  development,  e.g.,  hermaphroditism,  anor- 
chism,  hypospadias,  epispadias,  &c.  In  male  hermaphrodites 
[Jiermaphroditismus  transverstts  virilis)  the  mammae  are  almost 
invariably  hypertrophied,  as  in  the  following  instances  : — 


«"  CEsterr,  Med.  Jahrh.,  Bd.  xix.,  S.  3. 

=*'  Lancet,  vol.  i,  1868,  p.  285. 

**'-  Dublin  Med.  Jour.,  vol.  xli,  p.  457. 


IIO  HYrERTROPHY/ 

Polaillon'^  met  with  a  person,  aged  27,  with  large,  well  developed 
mammae  of  the  female  type.  The  beardless  face,  soft  skin,  voice,  sexual 
instincts  and  general  tastes  were  all  suggestive  of  femininity  ;  how- 
ever, menstruation  had  never  supervened.  On  examination  the  vulva, 
clitoris  and  meatus  were  normal.  The  vagina  was  represented  by  a  shallow 
depression.  No  trace  of  a  uterus  could  be  felt  on  recto-abdominal  palpation. 
In  each  inguinal  canal  there  was  a  firm,  tender  body.  This  person  after- 
wards led  an  irregular  life  ;  and  constant  attempts  at  coitus  deepened  the 
rudimentary  vagina.  She  subsequently  died  from  albuminuria.  After  death 
the  sexual  organs  were  carefully  dissected.  A  recto- vesical  pouch  of  the  male 
type  was  discovered.  Below  its  reflection,  just  in  front  of  the  blind  end  of 
the  vagina,  in  the  middle  line,  was  a  mass  of  unstriped  muscle  tissue  the 
size  of  a  haricot  bean,  which  might  have  represented  either  uterus  or  pros- 
tate. Two  cords  proceeded  from  this  mass  to  the  bodies  in  the  inguinal 
canal,  which  proved  to  be  testes,  but  the  epithelial  lining  of  the  tubuli  semi- 
niferi  were  atrophied.  In  all  other  respects,  except  in  the  absence  of  uterus, 
tubes  and  catamenial  phenomena,  the  person  was  female. 

Kochenburger*^^  has  reported  a  similar  case.  The  patient  was  33,  and 
had  never  menstruated.  She  had  been  married  for  ten  years,  but  coitus 
was  difficult,  and  she  never  felt  any  desire.  She  was  large  in  frame,  but 
feminine  in  form,  with  well  developed  breasts  and  mons  veneris.  The  vagina 
formed  a  blind  sac,  about  two  inches  deep.  An  elastic  body  the  size  of  a 
broad  bean,  lying  rather  to  the  right,  appeared  to  represent  the  uterus.  In 
each  labium  majus  was  a  firm,  ovoid,  but  very  tender  body.  These  weie 
excised.  Histologically  examined  they  proved  to  be  testes,  containing 
tubuli  seminiferi,  and  not  Graffian  follicles. 

I  have  given  an  abstract  of  an  almost  identical  case  by  Chambers,  in 
a  preceding  chapter.''-' 

Ledentu^^  has  seen  an  instance  of  ectropia  testis  associated 
with  hypertrophy  of  the  corresponding  breast. 

(2)  Certain  diseases  that  entail  destruction  of  the  testicular 
substance,  such  as  syphilitic  orchitis,  traumatic  orchitis,  the 
orchitis  of  mumps,  &c.,  are  after  a  time  apt  to  be  followed  by 
hypertrophy  of  the  breasts.  This  sequence  is  of  commoner 
occurrence  after  the  orchitis  of  mumps,  which  so  often  causes 
atrophy,  than  after  any  other  form  of  the  disease. 

In  a  case  by  Lereboullet,"  a  robust  young  man,  aged  22,  presenting  all 
the  characters  of  virility,  was  attacked  with  mumps.     The  disease  seemed 


«•  Bull,  de  PAcad.  de  Mid.,  7  av.,  1891. 

"*  Zeiischr.  f.  Geburish.  u.  Gyn'dk.,  Bd.  xxvi.,  1893,  ''^-  73 

"■'■  Chapter  iii.,  p.  37. 

*'   Thhe  de  Paris,  1869.     "  Anomalies  du  Testicule." 

"'  Gaz.  held,  de  Mhi.et  de  Chir.,  1877,  pp.  533  and  542. 


GYN/ECOMASTIA.  I  I  I 

mild,  but  on  the  fourth  day,  though  the  parotitis  had  not  disappeared, 
double  orchitis  came  on.  Rapidly  progressive  testicular  atrophy  soon  after- 
wards set  in,  with  failure  of  sexual  power  and  desire,  and  hypertrophy  of 
both  mammce. 

Similar  instances  have  been  reported  by  Charcot^  and  others. 
Tubercular  and  gonorrhceal  affections  seem  seldom  to  cause  this 
result,  probably  because  in  these  diseases  the  morbid  process 
centres  in  the  epididymis  rather  than  in  the  testicle  itself.  Gal- 
liet^^  has,  however,  reported  two  cases  of  gynaecomastism  coin- 
cident with  diseases  of  the  epididymis. 

In  another  class  of  cases,  atrophy  of  the  testes  and  conse- 
quent gynaecomastism,  are  but  the  expressions  of  general  con- 
stitutional debility  and  degeneration  ;  such  individuals  present 
signs  of  femininism,  and  they  often  become  tubercular. 

(3)  Lastly  come  the  cases  in  which  gynaecomastism  has 
resulted  from  traumatic  destruction  of  the  testes,  or  from  their 
surgical  removal. 

Of  the  former  condition,  the  case  of  two  soldiers,  mutilated  by  the  explo- 
sion of  a  shell,  as  recorded  by  Martin,^"  is  a  typical  example.  Soon  after  the 
loss  of  their  testes,  the  breasts  began  to  enlarge.  Gorham^^  long  ago  reported 
a  similar  case. 

Much  light  may  be  thrown  on  the  interpretation  of  the  fore- 
going phenomena,  by  studying  the  effects  of  castration.  When 
this  operation  is  practised  prior  to  puberty,  gynaecomastism 
hardly  ever  ensues ;  hence  oriental  eunuchs,  who  are  castrated 
at  a  very  early  age,  are  never  affected  in  this  way.  Similarly, 
castration  of  adults  over  30  years  of  age,  is  hardly  ever  followed 
by  mammary  hypertrophy.  It  is  only  when  testicular  destruc- 
tion supervenes  during  the  heyday  of  sexual  life,  that  gynaeco- 
mastism subsequently  ensues.  As  previously  mentioned,^-  in 
women,  the  effect  of  removal  of  the  ovaries,  under  similar  con- 
ditions, is  to  determine  mammary  atrophy. 


^^  Soc.de  Chi)'.,  ii  mars,  1891. 

«^  C.  R.  de  la  Soc.  de  Biologie,  fev.,  1850. 

™  Gaz.  hehd.  de  MM.  et  de  Chir.,  1877,  p.  591. 

^'  London  Med.  Gaz.,  vol.  ii.,  1839-40,  p.  659. 

"'^  Chapter  iii.,  p  41. 


112  HYPERTROPHY. 

How  can  we  explain  these  remarkable  and  apparently  con- 
tradictory phenomena  ?  I  think  they  may  be  rendered  intel- 
ligible, if  we  bear  in  mind  the  principle  of  correlated  variability 
and  the  doctrine  of  the  latent  hermaphroditism  of  every  human 
being.  It  is  a  very  remarkable  fact  that  in  every  female  all  the 
secondary  male  characters,  and  in  ever}-  male  all  the  secondary 
female  characters,  exist  in  a  latent  state,  ready  to  be  evolved 
under  certain  conditions.  It  seems  perfectly  warrantable  to 
assume  that  the  normal  condition  of  the  mammae  in  each  sex 
is  determined  by  correlation  with  the  essential  sexual  organs. 
When  the  latter  are  destroyed  the  correlated  integrating  force 
determining  mammary  development  also  fails,  so  that  the  latent 
tendency  to  develop  the  opposite  secondary  sexual  characters 
then  becomes  manifest. 

Gynaecomastism  entails  no  ill  consequences ;  but  for  those 
who  desire  to  be  relieved  of  the  deformity  the  following  opera- 
tion may  be  done.  A  curved  incision  is  made  along  the  lower 
part  of  the  periphery  of  the  enlarged  organ,  and  through  this 
the  gland  is  removed,  together  with  its  fibro-fatty  envelope. 
The  nipple,  areola  and  overlying  skin  are  preserved,  as  well 
as  sufficient  of  the  subcutaneous  fat  to  ensure  the  vitality  of 
these  parts. 


1 1 


CHAPTER  VI. 
Histology  and  Neoplastic  Pathogeny. 


§     I . Histology. 

Inasmuch  as  the  mammary  epithelium  is  derived  by  descent 
from  the  columnar  cells  of  the  epidermis,  it  is  not  surprising 
that  throughout  the  whole  gland  these  cells  partake  more  or  less 
of  the  columnar  type.  The  flattened  cells  that  cover  the  surface 
of  the  nipple  penetrate  but  a  very  short  distance  into  the  galac- 
tophorous  ducts.     The  latter  are  lined  by  a  layer  of  columnar 


Fig.  20. — Histological  Section  of  a  Fully  Developed  Mammary  Acinus 
DURING  Lactation  {De  Sinity). 
{a)  Epithelial  cell ;    (/')  Nucleus  ;  {c)  Nucleolus  ;  (^)  Milk  globules  ;  {e)  Fibrous 
stroma  ;  (/)  Connective  tissue  cells  (  X  300  dia.). 

cells,  which  is  often  double ;  but  throughout  the  rest  of  the  gland 
the  epithelium  is  single-layered.  As  the  ducts  get  smaller  and 
approach  the  acini,  their  epithelium  gets  shorter  and  more 
cubical ;  while  in  the  smallest  ducts,  and  in  the  acini  themselves, 
the  cells  are  of  the  flattened  cubical  or  even  polygonal  type. 
In  the  structure  of  a  fully  developed  acinus,  according  to 


114 


HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 


De  Sinety,  five  distinct  layers  may  be  recognised  from  within 
outwards. 

(i)  A  single  layer  of  flattened  cubical  epithelial  cells,  each 
with  its  nucleus  and  nucleolus. 

(2)  An  endothelial  layer  situated  between  the  epithelial  cells 
and  the  membrana  propria,  which  is  rendered  visible  by  staining 
with  nitrate  of  silver. 

(3)  The  membrana  propria  a  thin,  pellucid  layer,  difficult  to 
demonstrate  in  the  physiological  state  ;  but  easily  seen  under 
certain  pathological  conditions.  It  appears  to  be  a  myxomatous 
modification  of  the  peri-acinous  connective  tissue,  consisting  of 
a  network  of  flattened  branching  cells,  embedded  in  hyaline 
matrix.  Processes  of  the  surrounding  peri-acinous  fibrous  tissue 
often  project  into  it. 


Fig.  21. — An  expanded  acinus  with  the  epithelial  lining  partially  removed,  so  as 
to  show  the  memhf-ana propria  (Moiillin). 

(4)  Immediately  outside  the  membrana  propria  and  con- 
tinuous with  it,  Labbe  and  Coyne^  have  pointed  out  that  a  thin 
transparent  layer  of  modified  connective  tissue,  devoid  of  lym- 
phatics, exists,  in  which  few  or  no  formed  elements  can  be  seen. 

(5)  A  much  thicker  layer,  external  to  the  foregoing,  con 
sisting  of  ordinary  fibrous  tissue,  rich  in  elastic  fibres  and  cells, 
the  latter  arranged  concentrically  around  the  acini.  It  blends  ex- 
ternally with  the  adjacent  inter-lobular  fibrous  stroma.  In  this 
layer  numerous  lymphatic  capillaries  and  lacuncB  are  met  with. 
These  completely  surround  the  acini ;  but  they  are  not  directly 


Traiti  des  Tutneurs  Bhtignes  du  Sein,  Paris,  1876,  p.  87. 


HISTOLOGICAL    METAMORPHOSES    OF    LACTATION.        II5 

in  contact  with  them,  owing  to  the  intervention  of  the  above- 
mentioned  clear  zone.  This  it  is  that  prevents  the  lymphatic 
system  from  being  invaded  in  the  earliest  stage  of  mammary 
cancer. 

Each  acinus  is  immediately  surrounded  by  a  dense  network 
of  capillary  blood  vessels,  which  form  a  system  for  the  different 
lobules.  The  exact  distribution  of  the  te7'minal  nej^ve  filaments 
is  unknown  ;  but  from  the  fact  that  nerve  filaments  have  been 
traced  to  secretory  cells  of  the  salivary  glands,  it  is  inferred  that 
they  may  be  similarly  connected  with  the  cells  of  the  mammary 
acini.  The  structure  of  the  smallest  ducts  is  similar  to  that  of 
the  acini ;  and  it  is  probable  that  these  parts  are  also  identical 
in  function. 

In  the  interlobular  fibrous  stroma  islets  of  fatty  tissue  are 
interspersed,  which  atrophy  during  lactation. 

From  this  account  of  the  histology  of  the  gland  it  will  be 
gathered  that  its  archiblastic  (epithelial)  and  parablastic  (con- 
nective tissue)  elements,  are  very  intimately  blended. 

§     II.  — Histological  Metamorplioses  of  Lactation. 

By  the  stimulus  of  conception  the  previously  functionless 
gland  is  gradually  converted  into  an  active  milk-secreting  organ. 
This  wonderful  transformation  is  brought  about  by  a  process  of 
progressive  ingrowing  gemmation  of  the  glandular  elements, 
with  differentiation  ;  which  is  essentially  of  the  same  nature 
as  that  of  the  embryonic  development,  of  which  it  is — like 
the  changes  at  puberty — but  a  superinduced  repetition.  During 
this  period  the  pre-existing,  as  well  as  the  newly  formed 
glandular  structures,  attain  their  highest  degree  of  morphological 
perfection. 

The  secretion  of  the  breast  is  elaborated  after  the  same  type 
as  that  of  a  sebaceous  gland,  of  which  the  following  is  a  brief 
description.  Within  the  membrana  propria  of  its  secretory 
part,  we  find  a  stratum  of  small,  irregularly-shaped,  epithelial 
cells,  each  with  a  large  nucleus  (fig.  22,  b\     The  cells  of  this 


ii6 


HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 


region  are  constantly  proliferating,  and  as  the  products  of  the 
process  gradually  shift  towards  the  duct,  they  become  changed 
and  gradually  form  the  secretion.  The  steps  of  the  process  are 
as  follows  : — The  cells  next  the  marginal  cells  (fig.  22,  b)  in- 
crease in  size  and  their  nuclei  dwindle.  As  they  approach  the 
centre  of  the  acinus  their  nuclei  disappear,  and  the  cells  become 
distended  with  granules  and  oil  globules.  Finally  they  burst 
and  their  debris  forms  the  secretion,  which  is  discharged.  These 
changes  may  be  compared  with  the  analogous  transformations 
of  the  cells  of  the  epidermis  which  eventuate  in  desquamation. 


Fig.  22.— Histological  Section  of  the  Wall  ok  a  Sebaceous  Cyst 
{Cornil  and  Ranvier). 
(a)  Fibrous  stratum  with  embedded  connective  tissue  corpuscles  ;  {b)  The  marginal 
stratum  ;  (c)  Hornifying  cells  ;  {</)  Sebaceous  cells. 


Lactation  is  the  outcome  of  a  similar  process.  Milk  must 
therefore  be  regarded  as  the  product  of  the  deliquescence  of 
successive  generations  of  epithelial  cells,  which  are  destroyed 
in  the  process,  and  replaced  by  relays  of  new  cells,  derived  by 
division  from  other  still  active  epithelial  cells  of  the  part.  Thus 
we  see  that  growth,  development  and  secretion,  are  but  slightly 
varied  manifestations  of  cellular  activity  finding  expression  in 
different  ways.     When  in  a  sebaceous  gland  the  metamorphoses 


HISTOLOGICAL    METAMORrHOSES    OF    LACTATION.        I  I  7 

of  the  cells  are,  from  any  cause  unduly  delayed,  the  constant 
proliferation  going  on  in  the  marginal  stratum  causes  great 
accumulation  of  imperfectly  changed  cells  to  arise,  instead  of 
the  proper  secretion  (fig.  22).  It  is  under  such  conditions  that 
sebaceous  cysts  originate.  Here,  the  formative  activity  of  the 
glandular  cells  predominates  over  their  secretory  activity.  Ab- 
normal processes  of  this  kind,  going  on  in  the  mammary  acini, 
play  an  important  part  in  the  origination  of  neoplasms. 

The  complete  degree  of  mammary  function  that  eventuates 
in  lactation  is  only  attained  periodically,  and  the  process  is 
always  gradual.     The  following  is  a  brief  account  of  Creighton's 


Fig.  23. — Mammary  lobule  near  the  FiG.    24. — Mammary  lobule  of  rising 

resting  stage  (Creighion).  function  {Creightoti). 

description  of  it.  Subsidence  of  function  goes  hand  in  hand 
with  undoing  of  structure,  and  revival  of  the  function  with  the 
building  up  of  structure.  Variations  of  intensity  in  the  secretory 
force  are  measured  by  its  products,  which  correspond  to  chang- 
ing aspects  of  the  secreting  acini.  The  beginning  of  the  rising 
function  coincides  with  the  beginning  of  pregnancy,  and  the 
process  occupies  the  entire  period  of  gestation.  During  the 
intervals  between  its  periods  of  functional  activity  the  breast 
remains  in  a  quiescent  functionless  state — the  resting  stage. 


it8         histology  and  neoplastic  pathogeny. 

In  this  condition  the  gland  is  shrunken  and  surrounded  by 
a  considerable  quantity  of  fibro-fatty  tissue.  The  acini  are 
shrivelled  up.  On  microscopical  examination  of  sections  of  the 
gland  in  this  stage  (fig.  23),  each  acinus  appears  as  an  alveolar 
space  bounded  by  a  thin  layer  of  fibrous  tissue,  denuded  of  epi- 
thelium. Its  contents  are  irregularly-arranged,  polymorphic, 
epithelial  cells,  with  large  nuclei  and  scanty  surrounding  proto- 
plasm. This  is  the  structure  that  is  mimicked  in  most  cases  of 
mammary  cancer. 

During  the  rising  function  the  size  of  the  acini  gradually 
increases  from  that  of  the  resting  stage.  The  cells  increase  in 
number  and  size,  and  acquire  more  protoplasm.  They  gradually 
arrange  themselves  so  as  to  form  a  lining  membrane  for  the  wall 
of  the  acinus  (fig.  24)  which,  as  lactation  approaches,  is  converted 
into  a  regular  mosaic.  The  cells  became  granular,  irregularly 
shaped,  excavated  and  vacuolated,  secreting  granular  and  mucous 
fluids.  The  milk  of  the  first  few  days  is  always  somewhat  crude, 
containing  colostrum  cells,  which  are  the  last  of  the  long  series 
of  secretory  products  thrown  off  during  the  period  of  rising 
function. 


Fic.  25. — Fully  expanded  mammary  acinus,  showing  the  epithelial  mosaic  {Creighton). 

The  fully  expanded  acinus  (fig.  25)  in  a  state  of  active  secre- 
tion, is  at  least  four  times  as  large  as  that  of  the  resting  stage. 
Its  contained  cells  are  much  more  numerous  than  at  any  other 
period,  and  they  form  a  perfect  mosaic,  lining  the  membrana 
propria.  Each  cell  is  flattened  and  of  polyhedric  shape,  and  has 
a  large  nucleus  surrounded  by  a  broad  zone  of  protoplasm. 


NEOPLASTIC  PROCESSES.  IIQ 

During  the  period  of  subsiding  function  the  organ  gradually 
reverts  to  the  resting  stage  through  the  converse  series  of 
changes.  In  this  process  the  cells  pass  through  a  succession  of 
transformations,  from  the  forms  characteristic  of  the  perfect 
mosaic  of  lactation  to  those  peculiar  to  the  various  stages  of  the 
subsiding  process.  These  changes  are  accompanied  by  constant 
destruction  and  renewal  of  the  participating  cells. 

It  will  be  gathered  from  this  description,  that  the  changes 
which  take  place  in  the  mammary  acini  during  the  periods  of 
functional  activity  are  but  a  slightly  modified,  sustained  repeti- 
tion of  those  of  the  ontological  development.  The  embryonic 
cells,  in  order  to  become  secreting  cells  of  the  mammary  acini, 
go  through  a  cycle  of  changes ;  and  the  changes  that  they 
undergo  are  precisely  those  that  the  cells  of  the  mature  organ 
undergo  in  producing  the  periodical  secretion. 

This  account  of  the  changes  in  the  gland  during  its  periods 
of  functional  activity  refers  almost  exclusively  to  its  archiblastic 
elements ;  but  its  parablastic  elements  are  somewhat  similarly 
affected,  although  in  a  less  degree. 

With  regard  to  the  influence  of  the  nervous  system  on  the 
mammary  secretion,  most  of  those  who  have  studied  the  subject 
are  agreed  that  the  secretion  of  milk  is  not  directly  under  its 
control.  Laffont,^  however,  maintains  that  the  mammae  possess 
vaso-dilator  nerves,  which,  when  stimulated,  cause  augmentation 
of  the  quantity  of  milk  secreted  ;  but  De  Sinety,^  who  has 
repeated  his  experiments,  is  unable  to  accept  his  conclusions. 

S     III. Neoplastic  Processes. 

It  now  remains  for  me  to  show  that  the  pathological  neo- 
plastic processes  of  the  breast  are  explicable  as  aberrant  repeti- 
tions of  these  normal  developmental  processes. 

In  my  work  on  the  "  Principles  of  Cancer  and  Tumour  For- 


-  Coniptes  Rendus  de  FAcad.  des  Set.,  1879,  t.  Ixxxix.,  p.  649. 
'  Mem  de  la  Soc.  de  Biol,  t.  i.,  1879,  p.  301. 


I20  HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 

mation,"  I  have  pointed  out  :  that  since  the  origin  and  develop- 
ment of  neoplasms  follows  a  course  homologous  with  that  of  the 
tissues  in  which  they  originate,  we  may  classify  these  growths, 
like  the  normal  tissues  in  association  with  which  they  develop, 
accordingly  as  they  originate  from  cell  derivatives  of  the  one  or 
the  other  of  the  germinal  layers.  That  is  to  say,  they  are  either 
of  archiblastic  (epithelial)  or parablastic  (connective  tissue)  origin. 
As  in  the  normal  development  the  cell  derivatives  of  the  blasto- 
dermic layers  are  never  transformed  into  each  other,  so,  under 
pathological  conditions,  no  such  metamorphoses  ever  occur. 

In  what  follows — for  the  sake  of  clearness — each  of  these 
classes  of  neoplasms  will  be  treated  separately  ;  although  in 
reality  elements  from  both  tissue-systems  are  almost  invariably 
concerned  in  every  mammary  neoplasm.  This  is  due  to  the  fact, 
that  nearly  all  such  neoplasms  originate  in  connection  with  the 
acini  or  small  ducts,  where  archiblastic  and  parablastic  struc- 
tures are  normally  very  intimately  blended. 

With  regard  to  the  origin  of  the  archiblastic  neoplasms,  it 
should  be  observed  that  during  the  period  of  rising  and  subsid- 
ing function,  the  secretory  metamorphosis  of  the  gland  cells  is 
incomplete  ;  so  that  instead  of  milk,  only  celhdar  products  result. 
Creighton  has  done  excellent  service  in  pointing  out  how  such 
cells  become  the  germs,  whence  cancer  and  other  epithelial 
neoplasms  originate.  He  says : — "  Taking  the  breast  at  the 
resting  state,  it  cannot  under  any  circumstances  reach  the  per- 
fection of  its  function  without  going  through  the  somewhat  slow 
series  of  unfolding  changes.  When  the  evolution  that  is  set  up 
is  of  a  spurious  kind,  or  in  other  words,  when  the  gland  is  dis- 
turbed from  its  resting  state  by  some  cause  other  than  preg- 
nancy, the  steps  of  its  unfolding  are  less  orderly  than  in  the 
normal  evolution  ;  and  the  fatality  of  the  morbid  process  con- 
sists in  this,  that  the  spurious  excitation  never  carries  the  gland 
to  the  end  of  its  unfolding,  or  to  the  perfect  function.  The  pro- 
ducts of  the  gland  never  get  beyond  the  crude  condition  ;  and 
it  is  the  crude  cellular  kind  of  secretory  product  that  makes  the 
tumour." 


NEOPLASTIC    PR0CP:SSES. 


121 


Cells  that  should  have  passed  out  of  the  gland  as  waste  pro- 
ducts, remain  at  their  place  of  origin,  where  they  proliferate  and 
aggregate  more  or  less  independently.  It  is  upon  such  devia- 
tions from  the  physiological  track  that  the  origin  of  most  archi- 
blastic  mammary  neoplasms  depends.  Neoplasms  of  this  kind 
generally  arise  at  a  time  when  the  breast  is  undergoing  the 
retrograde  changes  of  the  climacteric  period,  which  finally  even- 
tuate in  the  efifacement  of  its  secretory  mechanism,  and  the  with- 
drawal of  its  secretory  force.  Fragments  of  structure  with  corre- 
lated functional  force,  surviving  the  general  obsolescence,  are  the 
sources  to  which  we  must  look  for  the  origin  of  the  post- 
climacteric neoplasms.     It  makes  no  difference  in  this  respect 


Fig.  26. — A   pathological  acinus.      The   epithelium    massed    in    several    layers 
(Creighton). 

whether  the  glandular  elements  that  originate  the  disease  form 
part  of  the  gland  itself,  or  whether  they  exist  as  supernumerary 
structures  separated  by  sequestration  from  the  true  gland.  Ac- 
cording to  Creighton,  the  kind  of  cell  most  commonly  found  in 
such  mammary  tumours  is  the  large  nucleated  cell,  with  scanty 
surrounding  protoplasm.     Measured  on  the  physiological  scale. 


122 


HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 


these  cells  belong  to  the  intermediate  stage  of  the  unfolding 
process ;  they  stand  for  a  half-roused  physiological  stimulus. 
The  morbid  force  delays  at  this  intermediate  stage.  The  result 
is  the  accumulation  of  cellular  waste  products  instead  of  true 
secretion  (fig.  26).  The  formative  activity  of  the  cells  predom- 
inates over  their  secretory  activity.  This  accumulation  within 
the  acini  causes  them  to  become  greatly  enlarged.     Solid  bud- 


FiG.  27. — Histological  Section,  showing  thk  Pathocjenesis  of 
Cancer  (Gross), 
{a  b  c)  Enlarged  acini  packed  with  polymorphic  cells  of  which  the  peripheral  layer 
is  columnar.     At  a  and  c  the  epithelial  cells  are  invading  the  stroma.     Only  the 
stained  nuclei  of  the  cells  are  delineated  (  x   i8o  dia.). 


like  cellular  processes  arise  from  their  walls,  which  grow  and 
ramify  in  the  adjacent  tissues  (fig.  27). 

In  the  case  of  cancer,  the  process  seldom  advances  much 
beyond  this  low  grade  of  organisation  ;  but,  by  a  kind  of  con- 
tinuously progressive  gemmation,  which  is  merely  a  superinduced 
repetition  of  the  initial  process,  this  crude  formation  grows  and 


NEOPLASTIC  PROCESSES.  I  23 

reproduces  itself  indefinitely.  The  morbid  product,  however, 
always  has  a  certain  likeness  to  the  parent  tissues.  Hence  two 
forms  of  mammary  cancer  can  be  recognised — the  acinous  and 
the  tubular.  In  the  former — which  is  much  the  commoner — 
large  lobulated  nodules  are  developed,  having  an  alveolar  struc- 
ture roughly  resembling  acini  of  the  resting-stage ;  in  the  latter 
we  find  instead,  thin  branching  columns  of  epithelial  cells,  grow- 
ing into  the  connective  tissue  stroma,  and  presenting  an  ap- 
pearance not  unlike  that  of  ductal  structures.  All  such 
neoplasms  are  more  or  less  malignant.  The  development  of 
mammary  cancer  is  sometimes  accompanied  by  imperfect  secre- 
tion, as  shown  by  the  escape  of  fluid  from  the  nipple,  and  cysts 
occasionally  arise  from  the  same  cause.  This  is  the  nearest 
approach  to  normal  function  that  the  pathological  structure  ever 
attains. 

In  the  adenomata  a  much  higher  grade  of  organisation  is 
reached.  The  newly-formed  gland  tissue  tends  to  be  very  like 
the  normal,  although  it  falls  short  of  this  high  standard.  The 
cells  of  such  a  pathological  acinus  are  generally  massed  in 
several  layers  ;  and  intra-acinous  papillary  projections  are  often 
met  with.  The  lumen,  as  a  rule,  is  absent,  or  more  or  less 
occluded,  and  it  has  no  connection  with  the  excretory  duct. 
These  glandular  new  formations  are  invariably  associated  with 
considerable  overgrowth  of  the  peri-glandular  connective  tissue. 
Fibro-adenomata  are  incapable  of  producing  normal  secretion, 
but  they  are  very  prone  to  form  serous  and  mucous  fluids  which 
originate  cysts.^  Such  neoplasms  never  manifest  malignant 
properties. 

I  will  now  refer  briefly  to  the  origin  of  the  parablastic  or 
connective  tissue  neoplasms. 

At  an  early  period  of  embryonic  life  those  parts  of  the  breast 
where  connective  substances  will  subsequently  arise,  are  composed 
solely  of  closely  aggregated  parablastic  cells.     These  cells  are 


'  For   some  remarks   on  the  real  nature  uf   alleged  instances  of   milk-secreting 
fibro-adenomata  {vide  ch.  xviii.,  §  2). 


124  HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 

nothing  but  small  rounded  masses  of  nucleated  protoplasm. 
Such  is  the  embryonic  parablastic  tissue,  whence  any  kind  of  con- 
nective substance  may  subsequently  develop.  The  first  step  in 
the  evolution  of  the  mature  connective  tissues,  from  the  cellular 
embryonic  structure,  is  that  the  cells  become  separated  from 
one  another  by  the  differentiation  of  intercellular  substance 
from  their  protoplasm.  A  distinction  thus  arises  between  the 
cells  that  form,  and  the  intercellular  substance  that  is  formed. 
As  development  progresses  most  of  the  cells  are  used  up  and 
converted  into  special  tissues.  Usually,  however,  a  considerable 
number  persist,  embedded  in  the  intercellular  substance,  and  are 
still  capable  of  active  growth  and  development.  Such  cells  are 
especially  numerous  in  the  vicinity  of  the  acini  and  small  ducts. 
Under  ordinary  circumstances  these  cells  simply  concern  them- 
selves in  maintaining  the  normal  structures  ;  but  under  certain 
pathological  conditions  they  become  the  germs  whence  the 
various    parablastic    neoplasms    originate. 

When  the  embryonic  parablastic  new  formation,  formed  by 
the  proliferation  of  these  cells,  shows  little  or  no  tendency  to  ad- 
vance beyond  this  low  grade  of  organisation,  the  various  kinds 
of  sarcomata  arise.  These  neoplasms  consist  chiefly  of  rounded 
or  spindle-shaped  cells,  interspersed  with  fibrous  tissue  ;  and  with 
these  elements  altered  glandular  structures  are  usually  asso- 
ciated. The  degree  of  malignancy  of  such  tumours  will  be 
found  to  vary,  according  to  the  grade  of  organisation  attained 
by  the  parablastic  new  formation. 

In  addition  to  the  cellular  embryonic  form  of  connective 
tissue,  gelatinous,  fibrous,  calcareous,  fatty,  cartilaginous  and 
osseous  varitics  may  be  recognised.  These  differences  depend 
upon  the  character  of  the  constituent  cells,  the  relation  they 
bear  to  the  intercellular  substance,  and  the  physico-chemical 
constitution  of  the  latter.  Modifications  inter  se  cause  transfor- 
mations to  occur  between  the  different  connective  substances 
{inetaplasia). 

The  formation  of  gelatinous  tissue  from  the  embryonic  tissue 
takes  place  by  the  differentiation    of  soft,  hyaline,  intercellular 


NEOPLASTIC  PROCESSES.  I  25 

substance  containing  mucin.  In  this  the  cells  are  sparsely  em- 
bedded ;  they  may  be  of  rounded  shape,  when  they  are  generally 
isolated,  or  stellate,  when  they  usually  communicate  by  fine 
protoplasmic  processes.  In  its  grade  of  organisation,  gela- 
tinous tissue  occupies  an  intermediate  position,  between  the 
embryonic  parablastic  formation  on  the  one  hand,  and  the 
highly  developed  fibrous  and  fatty  tissues  on  the  other. 

As  I  have  previously  mentioned,  in  the  normal  condition,  the 
mammary  acini  and  small  ducts  are  immediately  surrounded  by 
a  thin  layer  of  this  tissue.  Pathological  new  formations  thus 
constituted  are  the  myxomata.  They  arise  from  the  parablastic 
cells  of  the  part,  in  just  the  same  way  as  the  sarcomata;  from 
which  they  differ  only  in  being  a  degree  higher  in  organisation. 
They  represent  immature  tissue,  and  are  comparatively  lowly 
organised,  hence  after  removal  they  often  recur  locally,  and  occa- 
sionally give  rise  to  metastases.  Gelatinous  tissue  in  neoplasms 
is  often  derived  by  metaplasia  from  fibrous  and  fatty  tissues ; 
under  these  circumstances  its  presence  is  not  of  such  serious 
import. 

Fibrous  tissue  may  be  regarded  as  a  further  development  of 
gelatinous  tissue.  In  its  evolution  the  diffluent,  mucin-bearing, 
intercellular  substance,  gradually  solidifies  and  fibrillates,  and  is 
converted  into  gelatine.  Some  histogenists  describe  fibrous 
tissue  as  originating  without  a  gelatinous  transformation,  by  the 
developing  cells  (fibroblasts)  arranging  themselves  into  compact 
masses  and  their  protoplasm  fibrillating.  In  the  developmental 
process,  the  cellular  elements  are  gradually  used  up,  and  many 
disappear.  However,  a  considerable  number  remain  embedded 
in  the  fibrillar  intercellular  substance.  It  is  to  abnormal  pro- 
liferation of  these  cells  that  the  fibromata  owe  their  origin.  The 
embryonic  tissue  thus  formed,  passes  into  fibrous  tissue  as  in 
the  normal  development.  Neoplasms  of  this  nature  are  highly 
organised  and  of  innocent  nature.  Strange  to  say,  they  are 
of  very  rare  occurrence  in  the  breast.  Fibrous  tissue  readily 
passes  by  metaplasia  into  gelatinous,  calcareous  or  ossiform 
states. 


126  HISTOLOGY    AND    NEOPLASTIC    PATHOGENY. 

Fatty  tissue  is  but  a  modication  of  ordinary  areolar  tissue, 
owing  to  the  deposition  of  fat  within  its  cells.  The  panniculus 
adiposus,  whence  the  mammary  fatty  envelope  is  derived,  is  in 
the  foetus,  a  gelatinous  tissue.  In  its  evolution  fatty  tissue 
passes  through  the  cellular  and  gelatinous  stages;  but  while 
fibrillation  is  still  incomplete,  the  cells  form  groups  and  fat 
accumulates  within  them.  The  accumulation  of  fat  within  the 
cell  causes  its  nucleus,  with  the  little  remaining  protoplasm,  to 
be  pressed  against  the  cell  wall.  These  cells,  however,  are  still 
capable,  under  pathological  conditions,  of  taking  on  fresh  activity. 
Embryonic  parablastic  tissue  is  thus  formed,  which  finally  de- 
velops into  fatty  tissue  as  in  the  normal  evolution.  Thus  the 
lipomata  arise  from  normal  fatty  tissue. 


127 


CHAPTER   VII. 


The  Varieties  of  Mammary  Neoplasms  and  their 
Relative  Frequency. 

In  no  part  of  the  body,  except  the  uterus,  do  neoplasms 
arise  so  frequently  as  in  the  mammae. 

On  making  an  analysis  of  13,824  primary  neoplasms  of  all 
parts,  consecutively  under  treatment  at  Middlesex,  University 
College,  St.  Thomas',  and  St.  Bartholomew's  hospitals  during 
the  16  to  21  years  preceding  1889,  I  have  found  that  2,422 
(i7'5  per  cent.)  originated  in  the  breast  (males  25,  females  2397). 

The  following  tables,  based  on  these  13,824  cases,  show 
the  relative  frequency  of  the  neoplastic  process  in  its  chief 
seats : — 

Table  I. 

A.  Showing  the  Relative  Frequency  of  the  Neoplastic  Process  i?i 
its  Chief  Seats  in  both  Sexes  {based  on  13,824  cases). 

Per  cent. 

Uterus...         ...         ...         ...         ...         ...         I9'2 


Mammge 

Skin 

Connective  tissue  (general) 

Tongue  and  mouth 

Ovaries 

External  genitalia 

Bones  {ex.  maxillae) 

Rectum 

Maxillae 

Stomach 

Lower  lip 

All  other  locahties 


17-5 
9*4 
77 
6-3 
5-8 

5"i 

4-0 

3'2> 
2-9 
2-6 
2-6 
13-6 


128 


VARIETIES    OF    MAMMARY    NEOPLASMS. 


B.  Showing  the  Relative  Frequency  of  the  Neoplastic  Process  tti 
its  Chief  Seats  in  Males  {based  on  4.597  cases'). 

Per  cent. 

i6'4 


Skin      

Tongue  and  mouth    ... 

Connective  tissue  (general)  ., 

Lips 

External  genitalia 

Bones  {ex.  maxillae)    ... 

Rectum  

Stomach 

Maxillae  

Brain    ... 

Qisophagus     

Testes  ... 

Mammae 

Prostate 

All  other  localities     


159 

9"4 
7-3 
6-1 
6-1 
5-0 
4-8 
3'9 
3*4 
3'i 

2'0 

o"5 

0'2 
15-9 

lOO'O 


C.  Showing  the  Relative  Frequency  of  the  Neoplastic  Process  in 
its  Chief  Seats  in  Females  {based  on  9,227  cases). 

Per  cent. 


\J  ICIU^  ... 

Mammas          

..     26-0 

Ovaries 

..       87 

Connective  tissue  (general) 

..       6-9 

Skin      

••       5-9 

External  genitalia 

..       4-6 

Bones  {ex.  maxillae)   ... 

..       2-9 

Rectum            

..      2-5 

MaxilUe            

..      2-4 

Tongue  and  mouth    ... 

..       r6 

Brain    ... 

1-4 

Stomach 

i"4 

Liver     

I '2 

All  other  localities     ... 

..       5-8 

A  noteworthy  feature  in  connection  with  these  analyses  is 
the  great  frequency  with  which,  in  females,  the  reproductive 
organs — uterus,  mammre,  ovaries,  &c. — are  attacked  ;  in  fact, 
nearly  70  per  cent,  of  all  neoplasms  in  women  arise  from  these 
organs. 


VARIETIES    OF    MAMMARY    NEOPLASMS.  1 29 

The  very  great  frequency  with  which  the  uterus  and 
mammae  are  affected  is  particularly  striking.  From  the  fact 
that  both  of  these  parts  are  subject  to  remarkable  post-em- 
bryonic developmental  changes,  it  may  be  inferred  that  they 
are  normally  rich  in  cells,  which  still  retain  much  of  their 
embryonic  capabilities  for  growth  and  development.  It  is 
probably  owing  to  this  peculiarity  that  they  are  so  much  more 
prone  to  originate  neoplasms  than  other  parts  of  the  body. 

The  following  considerations  tell  in  favour  of  this  view  : — It 
may  be  said  of  neoplasms  in  general,  that  they  arise  from 
archiblastic  (epithelial)  structures,  much  more  frequently  than 
they  do  from  parablastic  (connective  tissue)  ones.  Thus,  of 
these  13,824  primary  neoplasms,  72  per  cent,  originated  from 
the  archiblast,  and  only  28  per  cent,  from  the  parablast.  In 
the  breast  archiblastic  neoplasms  predominate  to  a  still  greater 
degree,  for  I  have  found  that  no  less  than  9574  per  cent,  of  all 
such  neoplasms  have  this  origin,  whereas  only  4'26  per  cent, 
arise  from  the  parablast.  Now,  of  all  the  tissues  of  the  body, 
the  archiblastic  ones  have  on  the  whole  departed  less  from  the 
primordial  type  than  any  others,  hence  their  cells  still  retain 
their  primitive  powers  of  growth  and  reproduction  in  a  higher 
degree  than  others.  It  is  to  this  that  I  attribute  the  greater 
proneness  of  archiblastic  tissues  to  originate  neoplasms  under 
pathological  conditions. 

Again,  the  liability  of  the  tissue  systems  of  the  various 
organs  to  originate  neoplasms  is  not  diffused  equally  throughout 
their  whole  extent,  but  it  is  much  greater  in  certain  parts  than 
in  others.  In  the  breast,  for  instance,  most  neoplasms  originate 
in  the  immediate  vicinity  of  the  acini  and  small  ducts  ;  whereas 
it  is  very  rare  for  such  growths  to  arise  from  the  skin  of  the 
mammary  region,  the  areola,  the  nipple,  the  large  ducts,  or  the 
para-mammary  fibro-fatty  tissue.  That  is  to  say,  the  majority 
of  mammary  neoplasms  arise  in  the  seats  of  greatest  post- 
embryonic  developmental  activity,  where  it  may  be  inferred  that 
cells  still  capable  of  growth  and  development  most  abound. 

The  relative   frequency  of  the  occurrence  of  the  different 

9 


I  T,0 


VARIETIES    OF    MAMMARY    NEOPLASMS. 


varieties  of  mammary  neoplasms  is  shown  in  the  subjoined 
table,  which  I  have  compiled  from  the  2,422  consecutive  cases 
of  primary  breast  neoplasms  previously  mentioned. 

Table  II. 

Analysis   of   2,422    Consecutive   Cases   of  Primary    Mammary 

Neoplasms. 


Cancer 

Sarcoma     ... 

Myxoma 

Fibro-adenoma 

Papilloma  ... 

Fibroma 

Lipoma 

Chondroma 

Angioma     ... 

Cystoma 

Total 


Males. 
16 

3 
2 
I 


25 


Females 

1,863 

92 

2 

3 
I 


63 


2,397 


Total. 
1,879 

95 
4 
373 
3 
I 
I 
I 
I 

64 

2,422 


Throughout  the  body  malignant  neoplasms  occur  with 
greater  relative  frequency  than  non-malignant  ones ;  I  have 
found  the  ratio  to  be  64  per  cent,  of  the  former  to  '^6  per  cent, 
of  the  latter.  In  the  breast  the  relative  preponderance  of  malig- 
nant neoplasms  is  still  greater,  for,  as  the  above  table  shows, 
817  per  cent,  of  all  its  neoplasms  are  of  this  nature,  and  only 
i8"3  per  cent,  are  non-malignant. 

While  54*5  per  cent,  of  malignant  neoplasms  in  general 
spring  from  the  archiblast,  and  9*5  per  cent,  from  the  parablast, 
in  the  breast  'j'j'6  per  cent,  of  its  neoplasms  are  of  archiblastic, 
and  only  4T  per  cent,  of  parablastic,  origin. 

Of  non-malignant  neoplasms  in  general,  I7'5  per  cent,  (in- 
cluding cysts)  are  derived  from  the  archiblast,  and  i8'5  per 
cent,  from  the  parablast ;  whereas,  in  the  breast,  i8"i4  per  cent, 
of  its  non-malignant  neoplasms  are  of  archiblastic,  and  only 
0'i6  per  cent,  of  parablastic  origin. 

Or  the  facts  may  be  stated  thus  : — 


VARIETIES    OF    MAMMARY    NEOPLASMS.  I3I 

Table  III. 

Showing  the  Relative  Frequency  of  Neoplasms  in  General  and  of 
Female  Breast  Neoplasms. 


Neoplasms  in  General. 

Breast  Neoplasms. 

Per  cent. 

Per  cent. 

Cancers     

54-5            

777 

Sarcomas 

9"4         

3-9 

Non-malignant  neoplasms 

247         

157 

Cysts         

ii'4         

27 

lOO'O  lOO'O 

This  shows  that  the  relative  liability  of  the  female  breast  to 
cancers  is  very  much  above  the  average  ;  while  its  liability  to 
simple  cysts,  non-malignant  neoplasms,  and  sarcomas  is  below 
the  average. 

Some  idea  of  the  great  frequency  of  mammary  cancer  may 
be  gathered  from  an  estimate  I  have  made,  according  to  which 
there  cannot  be  fewer  than  10,000  women  now  suffering  from 
this  disease  in  England  and  Wales.  In  arriving  at  this  result 
I  have  taken  the  average  duration  of  cancerous  disease  in 
general  at  two  years,  which  is  probably  under  rather  than  over 
the  mark.  If  we  estimate  it  at  a  higher  figure,  then  the  number 
of  breast  cancer  cases  must  be  still  more  numerous. 

The  influence  of  sex  in  the  development  of  neoplasms  is  very 
great.  In  general,  females  are  about  twice  as  liable  as  males, 
the  percentage  proportion,  according  to  my  estimate,  being  Gy 
females  to  33  males.  In  the  breast,  however,  nearly  99  per  cent, 
of  all  its  neoplasms  occur  in  females,  and  only  about  i  per  cent, 
in  males.  This  is  a  good  illustration  of  the  lav/ — of  which  many 
other  instances  might  be  cited — that  functionless,  obsolete  struc- 
tures have  but  little  tendency  to  take  on  the  neoplastic  process. 
Herein  is  further  evidence  in  favour  of  the  view  I  have  advanced, 
that  neoplasms  are  most  prone  to  arise  in  the  sites  of  greatest 
post-embryonic  developmental  activity. 


132 


CHAPTER    VIII. 
The  Pathogeny  of  Cancer  and  other  Neoplasms, 

WITH  SPECIAL  reference  TO  THE  MICROBE  THEORY. 


S     I . Historical  Review. 

At  the  present  time  one  of  the  most  absorbing  pathological 
controversies  that  have  ever  arisen,  centres  round  the  pathogeny 
of  neoplasms. 

Before  entering  on  this  discussion,  it  will  be  profitable  briefly 
to  review  the  leading  opinions  prevalent  in  former  times  on  this 
subject.  The  ancients  divided  tumours  into  three  great  classes : 
— "  Tiunores  seciinduvi  naturam,  supra  naturain,  prater  natJiram." 
Physiological  enlargements  were  included  in  the  first  group,  the 
second  comprised  swellings  due  to  displacements  of  natural  parts  ; 
while  the  third  embraced  all  other  swellings — a  very  miscella- 
neous assemblage,  comprising  all  that  we  now  include  under 
the  term  "  tumour,"  and  many  other  conditions  besides. 

By  Galen^  and  his  followers  the  tumours  " prcster  naturam" 
were  believed  to  result  from  the  accumulation  of  one  or  other  of 
the  four  Jiuuionrs,  each  of  which  generated  its  corresponding  kind 
of  tumour.  Of  these  humoral  tumours,  those  of  the  group 
called  "  scirrlins  " — which  embraced  cancer,  and  nearly  corres- 
ponded with  what  we  now  understand  by  the  word  "tumour" — 
were  believed  to  arise  from  the  accumulution  of  atrabile.  It  was 
several  centuries  before  the  doctrine  of  the  four  humours  was 
overturned  by  the  discovery  of  the  circulation  of  the  blood  and 
the  lymph  (Harvey,  Malpighi,  &c.).  But  even  these  discoveries 
did  not  at  once  destroy  the  humoral  pathology,  the  essential 

'  "  De  tumoribus  proetcr  naluram." 


HISTORICAL    REVIEW.  I  33 

ideas  of  which,  in  slightly  modified  form,  continued  to  prevail 
until  the  eighteenth  century,  and  even  now  it  would  be  rash  to 
pronounce  them  altogether  extinct.  In  place  of  the  humours, 
the  blood  came  gradually  to  be  regarded  as  the  centre  of 
disease.  To  the  newly-discovered  lymph — a  derivative  of  the 
blood — the  Cartesians,  with  Boerhaave  at  their  head,  ascribed 
the  origin  of  all  tumours.  The  different  properties  of  the  latter 
they  attributed  to  its  varying  degrees  of  crudity,  density,  acridity, 
fermentation,  &c.  Cancer  they  regarded  as  the  outcome  of 
vitiated,  depraved  or  degenerated  lymph.  It  is  interesting  to 
note  the  precise  form  given  to  these  views  by  the  rank  and  file 
of  the  profession  of  that  age.  Happening,  not  long  ago,  to  meet 
with  a  well-written  essay  "  On  the  General  Method  of  Treating 
Cancerous  Tumours,"  dated  1753,  when  these  doctrines  were  in 
full  swing — by  one  William  Norford,  "  Surgeon  and  Man-mid- 
wife," evidently  a  very  up-to-date  practitioner  —  I  read  as 
follows  : — 

"  Messieurs  Du  Fouart  and  Faget,  in  the  '  Memoirs  of  the  Royal  Academy 
of  Surgery,'  at  Paris,  have  by  several  curious  Experiments  discovered  that 
cancerous  Tumours  are  formed  by  stagnant,  inspissated  lymphatic  and  gela- 
tinous juices  ;  which  by  a  putrid  dissolution,  are  thought  to  be  converted 
into  a  malignant  and  corrosive  Sanies^  that  soon  ulcerates  the  Flesh,  &c." 

Doctrines  of  this  kind  continued  to  hold  the  field  until  the 
time  of  Hunter.-  With  his  advent,  towards  the  end  of  the 
eighteenth  century,  observation  was  substituted  for  vain  theoris- 
ing, and  we  begin  to  discern  the  first  rudiments  of  modern  con- 
ceptions emerging  from  the  ancient  chaos.  The  merit  of 
Hunter's  work  with  regard  to  tumours  is,  that  by  studying  their 
structure  he  recognised  their  affinities  with  the  normal  tissues, 
from  which  he  maintained  they  arose  by  modification  of  the 
formative  process.  This  was  an  immense  advance  on  previous 
ideas.  In  Hunter's  time  it  was  believed  that  the  development  of 
the  various  tissues,  &c.,  commenced  by  the  secretion  of  a  plastic 
fluid,  derived  from  the  blood,  which  after  its  effusion  became  the 
centre  of  the  subsequent  developmental  changes.     To  this  sub- 

■  "  Hunter's  Works,"  Palmer's  edition. 


134  THE  PATHOGENY  OF  CANCER. 

stance  Hunter  gave  the  name  of  coagulable  lymph ;  and  to  its 
effusion  he  traced  the  origin  of  all  tumours,  whose  diverse  mor- 
phological and  dynamical  properties  did  not  escape  his  notice. 
He  thus  laid  the  foundations  of  the  anatomico-pathological 
study  of  tumours;  which  were  subsequently  further  strengthened 
by  Bichat,  Laennec,  Abernethy,  Cruveilhier,  &c. 

At  this  juncture  the  current  of  thought  was  suddenly  com- 
pletely changed,  by  the  appearance  on  the  scene  of  the  celebrated 
Broussais.^  His  doctrine  was  that  all  tumours,  including  cancer, 
were  but  forms  of  chronic  inflammation,  consequent  on  organic 
irritation.  The  extreme  simplicity,  comprehensiveness,  and 
positiveness  of  this  brilliant  generalisation — suddenly  sprung  on 
a  scientific  world,  hesitating  between  the  old  humoral  doctrines 
and  the  nascent  anatomico-pathological  tentatives — captivated 
everyone  ;  and  the  Broussaisian  system,  in  an  incredibly  short 
time,  became  supreme.     But  its  supremacy  was  short-lived. 

What  more  than  anything  else  contributed  to  its  downfall  was 
the  application  of  the  microscope  to  the  study  of  new  growths. 
This  instrument,  invented  towards  the  end  of  the  sixteenth  cen- 
tury, at  about  the  period  to  which  our  history  refers,  underwent 
important  improvements,  of  which  naturalists  quickly  availed 
themselves,  with  the  result  that  the  cellular  structure  of  organised 
bodies  was  ere  long  discovered.  For  the  famous  Ce//  Theory, 
which  must  be  ranked  among  the  most  important  steps  by  which 
the  science  of  biology  has  ever  been  advanced,  we  are  indebted 
to  the  vegetable  morphologist  Schleiden  ; '  and  shortly  afterwards 
Schwann'^  demonstrated  the  applicability  of  his  generalisations 
to  the  animal  world.  In  the  very  same  year  the  publication  of 
Miiller's  important  work,"  established  the  cellular  nature  of 
cancer  and  other  neoplasms.     At  this  period  the  cells  themselves 


'  "  Traite  des  I'lilegmasies  Cliroiiiciues,"    1808  ;    and    "  Exameii   des   Doctrines 
Mcdicales,"  1821. 

''  Beitrujre  zttr  Phylogenesis,  183S. 

*  Mikfoscop.    Untersuchtingcn  ilhei'  die  Uebe  reins  tint  in  ung  in   der  Slnutiir  und 
dein  Wachstlmin  der  Thieve  und  PJlanzcn,  1838. 

*  Ucbcr  der  feineren  Ban  und  die  For  men  der  krankha/ten  Geschwnlste,  1838. 


HISTORICyVL    REVIEW.  I  35 

were  believed  to  originate  from  a  formative  fluid  exuded  from 
the  blood  {blastema  or  cytoblasteina),  which  was  nothing  but  the 
"  coagulable  lymph  "  of  Hunter  under  another  name.  The  origin 
of  cancer  and  other  neoplasms,  and  their  variations  inter  se,  were 
ascribed  to  aberrations  of  the  force  inherent  to  this  primordial 
substance,  causing  the  resulting  cells  to  deviate  from  their  usual 
evolution.  Like  Hunter,  Miiller  strongly  insisted  on  the  corres- 
pondence between  the  development  from  the  embryo  and  the 
pathological  neoplastic  process.  Pathological  cells,  he  main- 
tained, differed  from  physiological  cells  only  in  respect  to  the 
degree  of  evolution  ultimately  attained.  Laennec's  division^  of 
neoplasms  into  two  great  classes,  according  as  their  structure 
resembled  the  normal  tissues  {homologous)  or  differed  from  them 
{heterologous),  Miiller  completely  rejected.  "  It  is  evident,"  he 
says,  "  that  no  division  of  pathological  structures  into  homo- 
logous and  heterologous  can  be  established.  Such  a  classifica- 
tion is  formed  without  any  knowledge  of  the  structure  of  morbid 
growths,  and  is  founded  on  blind  gratuitous  hypothesis.  The 
most  innocent  growths  do  not  differ  in  their  minute  elements, 
nor  in  their  origin,  from  the  most  malignant  ones." 

The  establishment  of  the  cell  theory  gave  an  immense  im- 
petus to  pathological  histology,  and  a  vast  mass  of  new  data 
soon  accumulated.  Virchow,^  twenty  years  later,  pounced  upon 
these  ;  and,  with  wonderful  insight,  skill  and  energy,  elaborated 
them  together  with  independent  observations,  into  a  kind  of  new 
cell  theory,  which  still  prevails.  Virchow's  influence  on  modern 
times  has  been  so  great  that  it  will  be  of  interest  to  trace  the 
genetic  relationship  of  his  ideas  with  those  of  his  predecessors. 
It  may  be  said  that  he  adopted  the  cell  theory  in  its  entirety,  as 
laid  down  by  Miiller,  with  the  single  important  exception  that 
he  completely  exorcised  the  blastemal  origin  of  cells.  It  was 
just  this  omission  that  chiefly  constituted  the  novelty  of  his 
system.     Instead  of  a  hypothetical  blastema  he  substituted  the 

•   "  Essai  sur  I'Anat.  Palh.,"  iSoS. 
'  "Cellular  Pathologie,"  1859. 


136  THE  PATHOGENY  OF  CANCER. 

famous  formula  "  Oinnis  cellula  e  celhild"  "  Where  a  cell  arises 
there  a  cell  must  have  previously  existed,  just  as  an  animal  can 
spring  only  from  an  animal,  and  a  plant  only  from  a  plant." 
Whence  it  follows  that  all  normal  and  pathological  structures 
are  evolved  from  cells  by  a  process  of  conthmoiis  development. 
Another  important  respect  in  which  Virchow's  cellular  pathology 
of  tumours  differs  from  that  of  his  predecessors,  is  in  the  addi- 
tion to  it  of  the  whilom  extinct  Broussaisian  doctrine  of  irritation 
and  chronic  inflammation,  "  Irritation,"  he  considers  to  be  the 
fundamental  cause  of  all  true  neoplastic  action.''  Nowhere  in  his 
works  have  I  met  with  any  attempt  to  explain  the  compatibility 
of  this  view,  with  the  doctrine  he  has  also  adopted  of  the  corres- 
pondence between  the  embryonic  and  neoplastic  developmental 
processes.  In  my  opinion  these  views  are  absolutely  incom- 
patible, and  this  incompatibility  constitutes  a  serious  flaw  in 
Virchow's  neoplastic  pathology. 

Of  late,  owing  to  a  variety  of  causes,  Virchow's  doctrines 
have  undoubtedly  lost  ground.  For  this  lapse  Virchow  himself 
is  to  a  large  extent  responsible,  because  he  has  gone  out  of  his 
way,  in  a  really  extraordinary  manner,  to  prevent  his  followers 
from  assimilating  the  new  facts  and  principles  brought  to  light 
by  modern  biological  progress  in  connection  with  the  doctrine 
of  evolution.  Hence,  while  the  rest  of  biology  has  been  com- 
pletely revolutionised,  the  cellular  pathology  has  remained 
stationary.  So  far  as  the  pathology  of  neoplasms  is  concerned, 
in  my  work  on  "  The  Principles  of  Cancer  and  Tumour  Forma- 
tion "  (1888),  I  endeavoured  to  repair  Virchow's  error  by  laying 
the  foundations  of  a  modified  cellular  pathology,  in  harmony 
with  modern  biology  ;  and  I  confidently  look  forward  to  the  time 
when  these  views  will  be  generally  accepted,  as  the  only  really 
scientific  basis  for  explaining  the  phenomena  of  pathological 
neoplasia.  To  this  end  nothing  will  be  more  conducive  than 
the  wider  spread  of  biological  knowledge  among  pathologists. 
There  is  profound  truth  in  this  saying  of  Savory's :  "  Before  we 
shall   ever   be  able   to  answer  the  question,   why   or   how   do 


'  Die  krankhaften  GeschwillsU,  Bd.  i.,  1863. 


THE    PRESENT    CONTROVERSY.  137 

tumours  form  ?  we  must  be  able  to  solve  the  problem  of  normal 
growth  and  development,  and  to  answer  the  question,  why  or 
how  it  is  that  these  continue  up  to  a  certain  point  and  then 
suddenly  cease  ?" 

Another  circumstance  that  has  tended  to  weaken  Virchow's 
authority  is  the  large  measure  of  success  accorded  to  a  modifi- 
cation of  the  cellular  theory,  propounded  by  Cohnheim,^°  accord- 
ing to  which  the  only  cells  of  the  body  capable  of  originating 
neoplasms  are  those  contained  within  detached  fragments  of  the 
various  organs,  &c.,  sequestrated  during  embryonic  life.  That 
a  considerable  proportion  of  malignant  and  non-malignant 
mammary  tumours  actually  do  arise  in  connection  with  such 
belated  sequestrations  I  have  elsewhere  demonstrated,^^  but  it 
seems  to  me  in  the  highest  degree  improbable  that  these  are  the 
only  cells  capable  of  originating  such  growths.  On  the  contrary, 
as  I  have  elsewhere  pointed  out,^^  there  are  good  reasons  for 
believing  that  neoplasms  may  arise  wherever  undifferentiated 
cells  are  present,  and  that  they  are  most  prone  to  originate 
where  such  cells  most  abound. 

But  what  more  than  any  other  recent  occurrence  has  under- 
mined the  authority  of  the  cellular  neoplastic  pathology,  is  the 
widespread  belief  that  neoplasms  will  eventually  turn  out  to  be 
of  microbic  origm.  In  short,  it  is  now  evident,  that  out  of  the 
confusion  of  a  transition  period,  but  two  conceptions  as  to  the 
origin  of  neoplasms  have  emerged;  the  one  based  on  the  cell 
theory,  and  the  other  on  the  germ  theory,  and  henceforth  the 
struggle  must  be  between  these  two. 

§     1 1. The  Present  Controversy. 

Briefly  stated,  the  question  now  is — do  cancers  and  other 
neoplasms  arise,  as  John  Hunter  and  Johannes  Miiller  main- 
tained, through  a  modification  of  the  formative  process  ;    or,  are 


'"  "  Lectures  on  General  Pathology,"  Syd.  Socy.  TransL,  vol  ii.,  1889,  p    746 
"  Ch.  iv.,  §  5. 

^"^  Annals  of  Surgery,  Oct.,   1891.      "The  Initial  Seats  of  Neoplasms  and  their 
Relative  Frequency."     See  also  Ch.  vii. 


138  THE  PATHOGENY  OF  CANCER. 

they  the  outcome  of  the  inflammatory  process,  owing  to  the 
presence  of  micro-organisms,  or  some  other  sources  of  irritation  ? 
In  other  words,  are  neoplasms,  from  first  to  last,  merely  the 
result  of  the  abnormal  play  of  forces  arising  within  the  body ; 
or  are  they,  directly  or  indirectly,  due  to  the  intrusion  of  some 
irritant  ab  extra  ?  I  incline  to  the  former  alternative ;  and  I 
think  the  future  will  see  decided  reaction  in  this  direction.  As 
I  have  elsewhere^^  fully  set  forth  my  views  on  this  subject,  1 
need  only  briefly  allude  to  them  here. 

In  the  genesis  of  neoplasms,  as  in  the  genesis  of  other 
organic  structures,  I  believe  that  we  must  take  into  consideration 
two  factors — the  cells  whence  they  originate,  and  \.\i&  force  that 
regulates  the  cellular  activities. 

With  regard  to  the  cells,  although  each  is  largely  dependent 
upon  others,  yet,  at  the  same  time,  each  manifests  a  certain 
independence  or  autonomy.  In  the  special  changes  underlying 
pathological  new  formations  the  autonomy  of  the  cells  plays  a 
very  important  part.  Herbert  Spencer^*  has  shown  that  we  are 
justified  in  assuming,  that  every  component  cell  of  the  multi- 
cellular organisms  has  the  inherent  power,  under  favourable 
conditions,  of  developing  itself  into  the  form  of  the  parental  or- 
ganism ;  so  that  each  cell  may  be  regarded  as  potentially  the 
whole  organism.  This  doctrine  has  lately  been  strenuously 
attacked  by  Weismann,^^  who  has  founded  his  theory  of  heredity 
on  the  assumption  that  the  reproductive  properties  of  somatic 
and  germ  cells  are  fundamentally  different.  In  my  opinion, 
the  validity  of  Spencer's  view  remains  unimpaired.  At  any 
rate,  it  is  quite  certain  that  somatic  cells  are  possessed  of  much 
greater  reproductive  powers  than  they  ever  ordinarily  manifest ; 
evidence  of  this  is  seen  in  the  process  of  repair,  and  in  a  variety 
of  other  pathological  processes.  Strange  to  relate,  this  won- 
derful  reproductive  capacity,  which  enables  us  to  understand 


"  "  The  Principles  of  Cancer  and  Tumuur  Form.ition,"  London,  1888. 
'*  "Principles  of  Biology."     1884. 
'*  "The  Germ  Plasm."     1893. 


THE    PRESENT    CONTROVERSY.  139 

how  a  single  cell  may  originate  the  largest  neoplasm  extant, 
has  received  but  scant  attention  from  pathologists  in  explaining 
the  neoplastic  process.  That  the  reproductive  activity  actually 
manifested  by  somatic  cells  usually  falls  so  far  short  of  their 
potentiality,  is  believed  by  Spencer  to  be  due  to  the  restraining 
and  modifying  influence  exerted  by  the  whole  organism  on 
their  protoplasm  ;  which  is  thus  compelled  to  the  performance 
of  other  comparatively  subordinate,  modified  functions.  In  the 
performance  of  these  special  duties  most  of  their  protoplasm  is 
metamorphosed  and  used  up.  Hence,  in  proportion  as  the 
cells  are  highly  specialised,  their  reproductive  function  is  either 
greatly  reduced  or  altpgether  lost.  But  in  the  higher  organisms 
certain  cells  never  attain  a  high  degree  of  development,  they 
remain  in  a  lowly  organised  condition,  and  serve,  according  as 
they  are  more  or  less  unspecialised,  either  as  germs  for  repro- 
ducing the  entire  individual,  or  for  forming  and  maintaining  the 
various  tissues  and  organs.  Cells  of  this  kind  abound  in  all 
parts  growing  and  capable  of  growth ;  they  are,  I  maintain,  tJie 
only  real  cancer  and  tumour  germs. 

With  regard  to  \)[\q  force  that  regulates  the  cellular  activities, 
first  a  few  words  as  to  its  reality.  In  the  ordinary  course  of 
organic  evolution,  the  processes  of  cell  growth  and  multiplication 
go  on,  until  the  amount  of  structure  proper  to  the  organism  has 
been  produced  ;  then  they  are  restricted  within  certain  limits. 
In  the  healthy  organism  this  state  of  balanced  equilibrium  is 
maintained  throughout  the  whole  life  of  the  individual.  Herein 
we  have  evidence  of  the  most  conclusive  kind,  of  a  force  regulat- 
ing the  growth  and  development  of  the  tissues  and  organs  in 
relation  to  each  other,  and  to  the  organism  as  a  whole.  As  long 
as  the  growing  cells  are  subject  to  this  normal  restraining 
influence — which  has  nothing  to  do  with  nerves  and  blood  vessels, 
themselves  integrated  structures — they  develop  in  a  regular  and 
orderly  manner,  in  accordance  with  the  specific  hereditary 
tendency  of  the  whole.  Spencer's  investigations  have  led  him 
to  conclude  that  the  natural  tendency  of  every  completely  emanci- 
pated, lowly  organised  cell  or  cellular  group,  when  placed  in  fit 


140  THE  PATHOGENY  OF  CANCER. 

conditions,  is  to  form  a  new  individual  by  agamogenesis.  But 
in  the  higher  organisms  the  component  cells  are  never  wholly 
undifferentiated,  and  their  emancipation  is  always  more  or  less 
incomplete,  so  that  in  them,  under  favourable  conditions,  instead 
of  new  individuals,  various  structural  modifications  result,  such 
as  new  tissues  and  neoplasms.  Thus  the  essence  of  the  neo- 
plastic process  is,  that  certain  cells  of  the  affected  part  grow  and 
multiply  more  rapidly  than  their  congeners.  I  explain  this  reju- 
venescence as  due  to  failure  of  the  integrative  force,  that  normally 
restrains  their  activities  within  proper  limits.  Under  these 
circumstances,  whenever  there  is  a  sufficient  supply  of  nutritive 
materials,  capable  of  being  utilised  for  growth  by  the  cells  of  the 
part,  there  a  neoplasm  will  arise ;  that  is  to  say,  the  abnormally 
emancipated  cells  will  there  grow  and  multiply  more  or  less 
independently,  regardless  of  the  requirements  of  the  adjacent 
tissues,  and  of  the  organism  as  a  whole.  Thus  the  process  by 
which  cancers  and  other  neoplasms  arise  may  be  regarded  as  a 
kind  of  abnormal  gemmation,  the  tumour  being  the  result  of  this 
modified,  superinduced  repetition  of  the  developmental  process ; 
and  its  qualities  the  result  of  the  grade  of  organisation  attained. 
Mitchell's^*'  conception  of  the  disease,  as  arising  by  what  he  calls 
"  histogenic  dissolution "  is,  I  think,  fundamentally  similar  to 
mine.  It  follows  from  the  foregoing,  that  the  genesis  of  cancer 
and  other  neoplasms,  is  a  phenomenon  of  the  same  order  as  dis- 
continuous growth  in  general. 

Before  setting  aside  these  views  in  favour  of  the  theory  of 
irritants  ab  extra,  I  think  strong  evidence  ought  to  be  forth- 
coming as  to  the  probability  of  the  latter  hypothesis  furnishing 
as  complete  an  explanation  of  the  phenomena  of  the  disease. 
Let  us  see  whether  this  is  the  case. 

Those  who  believe  that  neoplasms  are  caused  by  external 
irritants  may  be  divided  into  two  classes  :  the  Broussaisians  pure 
and  simple,  such  as  Hutchinson^'  and  Boyce,^^  who  consider  that 

"  "The  Philosophy  of  Tumour  Disease,"  London,  1S90. 

"  Archives  of  Surgery^  October,  1890,  p.  138. 

"*  British  Medical  Journal,  vol.  i.,  ib>94,  p.  219  ;   also  vol.  ii.,  1S92,  p.  678. 


THE    PRESENT    CONTROVERSY.  14I 

any  form  of  chronic  irritation  may  originate  the  disease,  whether 
of  microbic  origin  or  otherwise ;  and  the  exclusive  supporters  of 
the  germ  theory,  such  as  Soudakewitch,  Ruffer,  Pfeiffer,  Wick- 
ham,  &c.,  who  maintain  that  only  microbic  irritants  are  effectual. 
The  only  evidence  of  any  scientific  value,  hitherto  adduced 
in  favour  of  the  Broussaisian  doctrine,  is  Volkmann's.^^  He 
collected,  from  many  and  various  sources,  records  of  223  cases 
of  primary  cutaneous  cancer  of  the  extremities  ;  and  on 
analysing  these  he  found,  that  in  no  less  than  88  per  cent,  the 
cancerous  disease  had  originated  in  connection  with  some  pre- 
existing lesion  of  the  part;  in  only  12  per  cent,  did  it  appear 
to  have  sprung  up  spontaneously.  If  the  state  of  things 
revealed  by  this  analysis  could  be  proved  to  be  really  repre- 
sentative of  the  ordinary  mode  of  development  of  cancer,  these 
data  would  be  conclusive  evidence  in  favour  of  the  influence  of 
irritation.  But  I  maintain  that  it  is  not  so.  The  cases  analysed 
by  Volkmann  were  not  consecutive  cases,  but  most  of  them  had 
been  recorded  at  various  times  by  different  observers,  with  the 
special  object  of  showing  the  association  between  cancer  and 
pre-existing  disease,  as  to  the  occasional  occurrence  of  which 
there  is  no  doubt.  The  fallacy  of  accepting  these  data,  as 
typical  of  what  takes  place  in  the  ordinary  development  of 
cutaneous  cancer,  is  well  seen  by  comparing  Volkmann's  results 
with  the  following  analysis  of  forty  consecutive  cases  of  primary 
cutaneous  cancer  recorded  by  myself,^°  in  which  special  atten- 
tion was  directed  to  the  question  of  pre-existing  disease  of  the 
part.  Of  these  40  cases,  only  11,  or  27*5  per  cent.,  were 
associated  with  pre-existing  lesions — viz.,  old  scars  in  four  cases, 
congenital  lesions  in  two,  suppurating  sebaceous  cyst,  soot 
wart,  wart  of  eighteen  years  duration,  recent  wound  and  chronic 
sinus,  each  in  one  case.  In  other  words,  the  most  careful  ex- 
amination, directed  expressly  to  this  end,  failed  to  reveal  the 
presence  of  any  pre-existing  local  disease  in  72"5  per  cent,  of 


'"  Saiiiml.   klin.   Vortrage,  Nos.   334-335,  1889. 
-'•  Middlesex  Hasp.  Surg.  Reps.,  1882-89. 


142  THE  PATHOGENY  OF  CANCER. 

all  cases.  In  the  breast/^  uterus,  and  most  of  the  other  chief 
seats  of  cancer,  the  evidence  as  to  the  association  of  the  disease 
with  pre-existing  lesions  of  the  part  is  of  similar  tenour — the 
proportion  of  cases  in  which  such  association  is  traceable  very 
much  smaller.  It  is  evident,  therefore,  that  chronic  inflam- 
matory lesions  cannot  be  regarded  as  the  necessary  antecedents 
of  cancer.  In  the  great  majority  of  cases  the  outbreak  of  this 
disease  appears  to  be  entirely  spontaneous  ;  that  is  to  say,  it 
cannot  be  attributed  to  the  immediate  action  of  any  appreciable 
extrinsic  cause  whatever.  It  has,  however,  been  clearly  shown, 
that  repeated  irritations  of  long  duration  and  moderate  intensity 
are,  in  a  certain  proportion  of  cases,  the  precursors  of  neoplasia. 
Further,  I  think  we  are  justified  in  believing,  that  parts  thus 
chronically  irritated,  may  thereby  be  rendered  more  apt  to  take 
on  neoplastic  action  than  they  otherwise  would  have  been. 
Thus  may  we  account  for  the  great  relative  frequency  with 
which  certain  cutaneous  cancers  are  met  with,  such  as  those  to 
which  chimney  sweeps,  workers  in  tar,  paraffin,  and  other 
irritant  substances  are  subject.  But  this  is  a  totally  different 
thing  from  admitting  that  chronic  inflammatory  lesions  are  the 
necessary  antecedents  of  cancer,  the  doctrine  against  which  I 
protest. 

Perhaps  the  most  striking  feature  about  cancerous  growths 
is  the  wide  morphological  differences  that  obtain  between  them 
according  to  the  localities  whence  they  originate.  Herein 
they  differ  completely  from  the  inflammatory  pseudo-plasms, 
which  always  have  the  same  indifferent  structure,  no  matter 
in  what  part  of  the  body  they  arise.  What,  for  instance,  can 
be  more  divergent  in  this  respect  than  the  appearances  pre- 
sented on  microscopical  examination  by  sections  of  cancers 
from  such  different  parts  as  the  breast,  rectum,  and  skin.  We 
learn  from  such  examinations,  that  cancerous  growths  arc 
sufficiently  organised  to  present  unmistakable  histological 
resemblance  to  the  structures  whence  they  originate.     Another 

■-'  Q.  v.,  Ch.  X.,  §  7. 


THE    PRESENT    CONTROVERSY.  1 43 

remarkable  property  of  all  cancers  is  their  power  of  autonomous 
growth  and  development  (individuality),  upon  v/hich  their  so- 
called  parasitism  depends.  It  is  by  virtue  of  this  property 
that  cancers  tend  to  persist  and  increase  indefinitely. 

Nothing  in  the  least  degree  comparable  to  this  is  seen  in 
connection  with  any  of  the  inflammatory  pseudo-plasms,  which 
tend  to  disappear.  The  great  resemblance  always  noticeable 
between  primary  and  secondary  cancerous  growths  is  a  pheno- 
menon of  similar  import,  which  is  absolutely  unaccountable  on 
the  basis  of  inflammation  and  micro-organisms.  It  is  impossible 
to  conceive  a  valid  explanation  of  such  conditions,  without  the 
presence  of  epithelial  cells,  capable  of  growth,  multiplication, 
and  organisation,  these  phenomena  clearly  imply  that  the 
disease  centres  in  the  epithelial  cells  themselves.  Thus  there 
are  strong  d  priori  reasons  for  regarding  the  microbe  theory 
of  cancer  as  improbable. 

Now  let  us  turn  to  the  a  posteriori  side  of  the  question. 
Before  a  disease  can  properly  be  called  parasitic,  the  parasite 
must  be  found,  isolated,  and  the  disease  it  is  alleged  to  cause  must 
be  reproduced  by  its  inoculation.  How  far  has  the  hypothetical 
cancer  microbe  fulfilled  these  conditions?  Of  the  numerous 
researches  undertaken  of  late  with  a  view  to  finding  it,  all  have 
proved  abortive.  One  after  another  the  alleged  discoveries  of 
this  recalcitrant  organism  have  ended  only  in  disappointment. 
Where,  now,  are  the  specific  cancer  microbes  of  Rappin,  Freire, 
Scheurlen,  Schill,  Francke,  Lampiazi-Rubino,  Sanarelli,  Kubasoff, 
Russell  and  others  ?  Scheurlen  V^  cancer  bacillus  was  no  sooner 
announced  than  it  was  shown  by  Senger-'  and  others  to  be  no- 
thing but  a  potato  bacillus — one  of  the  several  kinds  of  organ- 
isms that  grow  readily  on  slices  of  potato.  The  "fuchsine 
bodies  "  described  by  RusselP^  as  "  the  characteristic  organism 
of  cancer,"  and  regarded  by  him  as  vegetable  parasites  of  the 


■--  Deutsche  med.  Woch,,  No.  48,  1887,  S.  1033. 

"^^  Berlin  klin.  Woch.,  No.   10,  1888,  S.  185. 

-'  Brit.  Med.  /ourn.,  vol.  ii.,  1S90,  p.  1356;  vol.  i.,  1891,  pp.  112  and  568. 


144  THE  PATHOGENY  OF  CANCER. 

same  order  as  the  yeast  plant,  have  since  been  met  with  in  a 
great  variety  of  conditions  ;  and  they  are  now  generally  re- 
garded as  nothing  but  proteid  coagula.*  It  seems  certain  that 
the  attempt  now  being  made  to  attribute  cancer  to  psorosper- 
mosis will  prove  equally  abortive.^^  In  any  event  it  is  evident 
that  the  protozoon  infesting  the  liver  and  intestines  of  rabbits, 
cannot  be  the  cause  of  cancer,  for  in  these  animals  the  hepatic 
lesions  are  not  really  cancerous;  they  consist  merely  of  dilated 
bile  ducts  containing  papillary  ingrowths.  If  the  animals  re- 
cover, as  usually  happens,  the  tumours  disappear  and  the  lesions 
completely  heal.  Moreover,  in  the  undoubted  instances  of 
psorospermosis  in  human  beings  observed  by  Albarran,  Eve, 
Silcock,  &c.,  the  induced  lesions  had  no  resemblance  whatever 
to  cancer. 

Of  the  many  special  researches  for  the  cancer  microbe  that 
have  yielded  only  negative  results  it  will  suffice  to  mention  those 
of  Shattock  and  Ballance,^*^  Senger,^''  Makara^^  and  Brazzole. 
Hitherto  the  net  result  of  all  this  bacteriological  pathology  has 
been  to  demonstrate  that,  although  under  certain  conditions 
various  micro-organisms  may  find  a  suitable  habitat  in  cancer- 
ous growths,  yet  these  have  nothing  whatever  to  do  with  the 
causation  of  the  disease.  In  spite  of  repeated  failures,  however, 
the  germ  pathologists  seem  now  to  be  more  confident  than  ever 
that  there  must  be  a  specific  cancer  microbe.-'^  I  should  like 
to  know  why?  since  we  can  so  well  account  for  all  of  the  pheno- 
mena of  the  disease  without  it.  It  appears  to  me  that  the 
agency  of  micro-organisms  is  no  more  necessary  to  account  for 
the  genesis  of  cancer  than  it  is  to  account  for  the  genesis  of 
a  tooth  or  a  hair.  The  microbe  of  cancer  has  not  yet  been 
discovered,  because  in  all  probability  it  does  not  exist. 


*  Arch./,  path.  Atmt.,  Bd.  cxxxii.,  Heft  3,  1893,  &c. 

**  Q.  v.,  Chapter  ix.,  §  3  ;  also  Chapter  xv. 

■■"  Trans.  Path.  Sor.   Loud.,  vol.  xxxviii. ,  18S7,  p.  413. 

'■"  Op.  cit. 

-•  Deutsche  med.  Woch.,  1888. 

■•*  Brit.  Med.  Jour.,  vol.  i.,  1891,  p.  565. 


THE    QUESTION    OF    CONTAGION.  1 45 

§    III , The  Question  of  Contagion. 

Of  the  many  attempts  that  have  been  made  to  transmit  cancer 
experimentally  from  human  beings  to  the  lower  animals,  the 
results  have  almost  invariably  been  negative  (Senger,  Senn, 
Billroth,  Duplay,  Shattock,  Klebs,  Maas,  &c.).  The  alleged 
successes  of  Langenbeck,  Follin,  Goujon,  and  others,  were  never 
rigorously  proved.  Recently  Mayet"*^  claims  to  have  succeeded 
in  artificially  producing  the  disease  in  a  white  rat  by  the  sub- 
cutaneous injection  of  a  filtered  glycerine  extract  of  human 
cancer.  At  the  post-niorteni  examination,  eleven  months  after 
the  injection,  two  cancerous  nodules,  each  the  size  of  a  pea, 
were  found  in  the  animal's  kidney.  These  may  very  well  have 
been  due  to  the  spontaneous  development  of  the  disease. 
Francke  and  De  Rechter's^^  alleged  successful  transmission  of 
human  cancer  to  the  white  mouse  probably  belongs  to  the  same 
category.  Dupuytren  fed  dogs  and  other  animals  for  consider- 
able periods  with  human  cancers,  but  they  did  not  acquire  the 
disease.  The  dogs  that  Alibert  caused  to  swallow  the  discharge 
from  cancerous  ulcers,  &c.,  experienced  similar  immunity. 

It  seems  reasonable  to  suppose  that  such  experiments  would 
have  a  better  chance  of  success  if  confined  to  animals  of  the 
same  species.  The  attempts  made  in  this  direction  by  Jeannel, 
Bert,  Senn,  Weber,  Koster,  Erbre,  Doutrelepont,  and  many 
others,  have,  however,  all  proved  abortive. 

Hanau^^  (rat  to  rat),  Wehr^^  (dog  to  dog),  and  Morau**^ 
(mouse  to  mouse),  now  allege  that,  after  numerous  failures,  they 
have  at  length  succeeded.  It  is  difficult  to  determine  the 
validity  of  these  claims,  especially  when  the  numerous  sources 
of  fallacy  are  borne  in  mind.  There  can  be  no  doubt  that  dogs, 
rats  and  mice  in  confinement  (especially  the  white  varieties), 


s"  V Union  Med.,  No.  20,  19  aoul,  1S93. 
="  Bull.  Acad,  de  Med.  Belgique,i.  x.,  1892,  p.  999. 
3-  Corresp.  Bl.  f.  scJnv.  Aerzte,  No.  11,  1889,  S.  334. 
^  Arch.f.  klin.  Chir.,  Bd.  xxxix.,  1889,  S.  226. 
^'  C.  R.  Soc.  de  BioL,  1891,  p.  289. 


10 


146  THE  PATHOGENY  OF  CANCER. 

are  very  prone  to  develop  cancer  spontaneously,  and  in  these 
animals  tubercle  is  a  common  disease  easily  mistaken  for  cancer. 
Having  in  view  the  fact  that  so  many  previous  experiments  of 
the  same  kind  have  ended  only  in  failure,  it  seems  prudent  for 
the  present  to  accept  these  alleged  successes  only  in  a  tentative 
sense.  Even  if  definitively  accepted  they  would  not  prove  the 
contagiousness  of  cancer,  but  merely  the  possibility  of  success- 
fully transplanting  the  morbid  tissue. 

With  regard  to  human  beings,  there  is  no  proof  that  cancer 
has  ever  been  communicated  from  one  individual  to  another.^^ 
The  attempts  made  by  Alibert  and  others  to  inoculate  them- 
selves and  their  pupils  with  the  disease  were  uniformly  unsuc- 
cessful. There  is  not  a  single  case  on  record  of  a  surgeon 
having  acquired  cancer  during  the  performance  of  operations 
for  its  removal,  notwithstanding  the  frequency  of  exposure  to 
infection  under  such  circumstances.  Of  the  thousands  of  per- 
sons habitually  engaged  in  attendance  upon  the  victims  of  this 
disease,  how  few  have  ever  become  similarly  affected.  Not- 
withstanding that  many  men  have  had  sexual  intercourse  with 
women  the  subjects  of  uterine  cancer,  there  is  not  a  single  well- 
authenticated  case  on  record  of  cancer  of  the  penis  acquired  in 
this  way.  The  number  of  cases  in  which  cancerous  disease  of 
the  uterus  and  penis  have  co-existed  in  husband  and  wife  is  so 
small  as  to  deprive  them  of  all  value  as  evidence  of  contagion. 
Of  134  men  with  cancer  of  the  penis  tabulated  by  Demarpray, 
only  one  had  a  wife  with  uterine  cancer.  Thus  there  is  every 
reason  to  believe,  that  cancer  is  not  inoculable ;  and  it  seems  to 
be  out  of  the  question  that  a  vims  in  any  way  comparable  to 
that  of  tubercle  or  syphilis  plays  any  part  in  its  genesis.  Here, 
again,  the  hypothetical  cancer  microbe  fails  to  make  good  its 
entity. 

Lately  the  attempt  has  been  made  to  utilise  the  irregularities 
invariably  met  with  in  the  topographical  distribution  of  cancer, 


^'  For  a  series  of  alleged  cases  to  the  contrary  vide  The  Lancet,  vol  ii.,  1887,  pp. 
727,  888,  919,  986,  1091,  1 145,  &c.  I  regard  these  siinply  as  highly  exceptional 
coincidences. 


THE    QUESTION    OF    CONTA(]ION.  1 47 

as  evidence  of  the  mfectiotis  nature  of  the  disease.  Arnaudet^^ 
was  the  first  to  formulate  these  ideas.  In  certain  remote  rural 
districts  in  Normandy  he  found  that  cancer  was  two  or  three 
times  more  prevalent  than  in  Paris.  He  also  adduced  instances 
of  cancers  co-existing  in  various  organs  of  persons  living  in 
certain  houses  or  in  their  vicinity.  Hence  he  concluded  that 
the  locality  where  a  cancer  patient  had  lived  was  contaminated  ; 
and  he  thought  it  probable  that  contagion  was  propagated  chiefly 
through  cider,  water,  &c.  Similar  views  have  since  been  advo- 
cated by  Sorel,^''  Rebulet,^^  Guelliot,^^  Fabre,**^  Fiessinger,*^ 
Webb,^^  Power,*^  and  others.  As  an  example  of  the  alleged 
epidemic  occurrence  of  cancer  Fiessinger  cites  the  following 
group  of  cases. 

In  a  small  village  a  woman  died  of  cancer  of  the  breast,  and  within  a 
comparatively  short  space  of  time,  two  other  women  lodging  in  the  house 
died  of  the  same  disease— rone  of  the  rectum  and  the  other  of  the  vulva  ; 
and,  after  a  certain  time,  two  neighbours  also  died — one  of  cancer  of  the 
stomach,  and  the  other  of  sarcoma  of  the  leg. 

On  the  strength  of  some  exceptional  coincidences  of  this 
kind,  without  any  other  requisite  data,  the  exaggerated  conclusion 
has  been  drawn  that  cancer  is  an  epidemic  disease,  and  such 
groups  of  cases  have  been  styled  cancer  epidemics  !  If  the 
alleged  epidemiology  of  cancer  has  no  surer  foundation  than 
this  to  rest  on,  the  less  said  about  it  the  better.  It  will  be  time 
enough  to  entertain  such  surmises  when  the  cancer  microbe  has 
been  discovered.  What  to  my  mind  completely  negatives  these 
assertions  is  the  significant  fact ;  that  in  the  crowded  cancer 
wards  of  the  Middlesex  Hospital,  during  the  last  20  years,  not  a 


^^  "  Le  cancer  dans  une  commune  de  Normandie,"  V Union  Med.,  25  av.,  1889, 
Normandie  Med.,  i  and  15  av.,  1890,  also  15  fev.,  1891.  "  Nouveaux  faits  a  I'appui 
de  la  nature  infectieux  du  cancer." 

^'  Normandie  Med.,  dec,  1890. 

'^  Normandie  Mid.,  I  sept.,  1891. 

^  Gaz.  des  Hop.,  No.  139,  1892. 

■"•  These  de  Lyon,  juillet,  1892.     "  De  la  Contagion  du  Cancer." 

■"  Rev.  de  Med.,  Jan.,  1893. 

■*-  Birmingham  Med.  Rev.,  1892. 

"  Brit.  Med.  Journal,  vol,  i.,  1894,  also  p.  1240  and  p.  1302. 


148  THE  PATHOGENY  OF  CANCER. 

single  instance  is  known  in  which  a  sister,  probationer,  nurse, 
ward-servant,  surgeon,  student  or  anyone  engaged  in  attendance 
on  the  cancer  patients,  has  ever  subsequently  developed  the 
disease.  The  question  of  the  prevalence  of  cancer  in  Normandy 
has  lately  been  investigated  by  a  committee  of  35  local  prac- 
titioners,^^ and  their  conclusion  is ;  that  although  the  disease  is 
undoubtedly  unduly  prevalent  in  certain  remote  hamlets — 
probably  in  consequence  of  heredity — yet,  when  the  whole  of 
Normandy  is  taken  into  consideration,  cancer  is  no  more  pre- 
valent there  than  elsewhere  in  France.  In  this  connection  it 
should  be  borne  in  mind  that  other  diseases  besides  cancer — 
deaf  mutism,  for  instance — manifest  similar  topographical 
variations. 

I  have  found  very  few  experiments  on  record  as  to  the  aiito- 
inociilability  of  cancer  in  the  lower  animals.  Senn's  attempts  on 
a  dog  failed.**^  In  human  beings  Hahn  '*''  claims  to  have  suc- 
ceeded in  transplanting  several  small  grafts  of  cancerous  skin 
from  one  side  of  a  woman's  chest  to  healthy  skin  on  the  other 
side  ;  and  Cornil '"'  has  related  a  similar  case.  This  amounts 
to  the  artificial  production  of  metastasis.  Senn  failed  in  an 
attempt  to  transplant  a  fragment  of  cutaneous  epithelioma  from 
a  man's  leg  into  the  connective  tissue  of  the  part.  The  chief 
evidence  as  to  the  auto-inoculability  of  cancer  is,  however, 
derived  from  clinical  observation.  This,  if  not  quite  conclusive, 
is  certainly  weighty.  In  a  considerable  number  of  cases  it  has 
been  observed,  that  when  cancerous  growths  have  remained  for 
some  time  in  contact  with  apparently  healthy  epithelial  surfaces, 
the  latter  have  at  length  become  cancerous,  as  if  by  direct 
implantation. 

Cripps  ''^  has  related  the  case  of  a  woman   with   extensive  cancerous 
ulceration  of  the  left  mammary  region,  who,  being  unable  to  put   on  any 


"  Brunon  Raoul,  "  Enquete  sur  le  Cancer  en  Normandie,"  &c.,  Rouen,  1893. 

'■'  "  Surgical  Bacteriology,"  1889,  p.  261. 

*"  RerUn  klin.   Woch.,  No.  21,  1888,  S.  413. 

*'  Le  Piogris  Mid.,  No.  26,  1891,  p.  522  ;  and  No.  27,  p.  5. 

**  Trans.  Path.  Soc,  London,  vol.  xxxii.,  1881,  p.  iii. 


THE    QUESTION    OF    CONTAGION.  1 49 

dress,  had  kept  her  arm — bent  at  a  right  angle — in  constant  contact  with 
the  disease  for  several  months.  In  consequence  of  this  the  skin  in  the 
vicinity  of  the  elbow  became  the  seat  of  a  cancerous  ulcer  several  inches  in 
diameter. 

A  somewhat  similar  case  had  been  previously  recorded  by 
De  Morgan.^'' 

He  says,  "  My  colleague,  Mr.  Shaw,  attended  a  woman  whose  pendulous 
breast — the  seat  at  its  most  dependent  part  of  ulcerated  cancer — rubbed 
against  the  skin  of  the  thorax.  At  the  point  of  contact  a  circular  patch  of 
cancerous  ulceration  (the  size  of  a  florin)  took  place,  the  intervening  skin 
between  this  and  the  fold  of  the  mamma  remaining  healthy." 

Many  facts  of  similar  import  have  been  noticed  in  various 
other  parts  of  the  body.  Klebs'^*^  has  seen  instances  in  which 
primary  cancer  of  one  part  of  the  alimentary  tract  has  been 
followed  by  the  development  of  cancerous  nodules  of  similar 
structure  at  other  parts  lower  down,  as  if  by  direct  implantation 
of  fragments  detached  from  the  primary  growth.  Cases  in 
which  the  disease  has  spread  by  direct  implantation,  from 
one  lip  to  another,  from  one  vocal  cord  to  the  other,  from  the 
tongue  to  the  buccal  mucous  membrane,  from  visceral  to  parietal 
pleura  and  peritoneum,  &c.,  have  been  recorded  by  Bergmann,^^ 
Kraske,^^  Liicke,^^  and  many  others, 

I  have  myself  seen  several  instances  of  the  kind,  especially  in 
the  mouth  and  bladder,  in  which  it  appeared  to  me  almost  cer- 
tain that  cancerous  growths  had  originated  in  this  way. 

Several  cases  have  been  recorded  which  go  to  show  that 
eroded  surfaces  may  become  infected  through  constant  contact 
with  the  discharge  from  cancerous  ulcers  ;  and  some  surgeons 
(Hahn,  Donitz,  Sabatier,  &c.)  believe  in  the  traumatic  dis- 
semination of  the  disease  through  infection  of  wounds  by 
the  escape  of  "  cancer  juice  "  during  operations. 

In  all  the  foregoing  instances  the  phenomena  met  with  more 


"  "  On  the  Origin  of  Cancer,"  London,  1872. 
"'  Handb.  der path.  Anat.,  Bd.  i.,  S.  190. 
^'  Berlin  klin.   Woch.,  No.  47,  1887,  S.  891. 
5"  Cent.f.  Chir.,  No.  48,  1884,  S.  801. 
"  Billroth  und  Pithd's  Handb.,  Bd.  ii.,  S.  50. 


150  THE    PATHOGENY    OF    CANCER. 

closely  resemble  those  of  tissue  grafting,  than  they  do  those 
resulting  from  the  inoculation  of  infectious  disease.  It  may  be 
inferred  that  the  morbid  epithelial  cells  are  themselves  the  infect- 
ing agents,  and  that  cancer  auto-inoculability  is  a  phenomenon 
of  the  same  order  as  cancer  metastasis.  The  evidence  here,  as 
before,  is  against  the  existence  of  a  specific  cancer  microbe. 


T5I 


CHAPTER  IX. 
The  Morphology  of  Mammary  Cancer. 


S     I, Introductory. 

The  term  "  cancer,"  after  having  in  tlie  past  undergone 
repeated  changes  of  meaning,  is  now  used  in  such  different 
senses,  that  it  is  necessary  for  those  who  employ  it  to  state  pre- 
cisely what  they  mean  by  it.  In  the  popular  sense  every  malig- 
nant neoplasm  is  a  cancer.  In  medical  science,  however,  the 
term  is  usually  restricted  to  certain  malignant  neoplasms,  which 
as  Waldeyer,^  Thiersch,^  and  others  have  shown,  are  of  epithelial 
origin.     This  is  the  sense  in  which  I  employ  it. 

Every  part  of  the  body  is  liable  to  its  own  peculiar  forms  of 
cancerous  growth,  and  the  diverse  characters  manifested  by  each 
variety,  according  to  its  seat  of  origin,  show  that  the  influence  of 
locality  in  determining  the  structure  and  progress  of  the  disease 
is  very  great. 

In  the  breast  two  types  may  be  recognised — the  tubular  and 
the  acinous.  These  terms,  as  applied  to  mammary  cancers, 
originated  with  Billroth  ;  but  they  are  used  by  him  in  a  different 
sense  to  what  I  employ  them.  According  to  my  views  the  great 
majority  of  breast  cancers — about  94  per  cent. — consist  entirely, 
or  almost  entirely,  of  structures  of  the  acinous  type,  the  tubular 
form  being  a  comparative  rarity.     I  regard  the  ordinary  scirrhus 


Arch.  f.  path.  Anal.,  Bd.  xli.,  S.  470,  "  Die  EnUvickluntj  der  Carcinume,'' 
"  Der  epithelial  Krebs  namenllich  der  Hant,"  1S65. 


152  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

or  alveolar  cancer  as  morphologically  of  the  former  type,  the 
alveoli  and  their  contents  roughly  representing  acini  in  the 
resting  stage.  The  latter  term  I  restrict  to  certain  cancers — 
histologically  often  very  duct-like  in  appearance — the  true  duct 
cancers.  These  are  usually  associated  with  cysts  and  intra- 
cystic  papillary  growths,  structures  hardly  ever  seen  in  connec- 
tion with  acinous  cancers.  The  former  spring  from  the 
mammary  ducts,  the  latter  from  the  acini.  This  classification 
enables  me  to  dispense  with  the  term  "  encephaloid,"  as  applied 
to  mammary  cancers  ;  for  when  the  villous  papillomata,  tubular 
cancers,  myxomata,  carcinoniata  myxomatodes,  and  sarcomata — 
hitherto  generally  confounded  under  this  head — have  been 
assigned  to  their  proper  groups,  nothing  remains  to  which  this 
obsolete  term  can  properly  be  applied. 

As  I  have  elsewhere^  fully  described  the  chief  pathological 
and  clinical  features  of  the  tubular  variety  of  mammary 
cancer,  what  I  ;iow  have  to  say  refers  exclusively  to  the  acinous 
form. 

Acinous  cancer  of  the  breast  usually  begins  as  a  small,  hard, 
solitary  nodule,  which,  though  movable,  is  connected  with  the 
mammary  parenchyma.  It  increases  slowly  and  painlessly,  but 
without  remission.  A  tumour  is  thus  formed  which,  however, 
seldom  attains  very  large  size.  As  the  disease  progresses  it 
causes  retraction  of  the  nipple,  and  dimpling  of  the  overlying 
skin.  The  latter  soon  becomes  adherent  to  the  tumour,  which 
eventually  ulcerates.  In  consequence  a  hard,  crateriform  ulcer 
forms,  which  spreads  slowly  but  never  heals.  In  like  manner 
the  other  adjacent  structures  are  gradually  invaded — pectoral 
muscles,  ribs,  pleura,  the  thoracic  viscera,  and  sometimes  even 
the  opposite  breast. 

At  a  comparatively  early  stage,  before  ulceration  sets  in, 
the  axillary  lymph  glands  become  enlarged,  and  secondary 
cancerous  growths  eventually  develop  in  them,  which  behave 
just  like  the  primary   one.       Finally,  similar   growths  arise  in 

'  Ch.  xiv. 


GENERAL    MORPHOLOGY.  153 

various  remote  parts  of  the  body,  such  as  the  liver,  lungs,  bones, 
&c.  As  the  disease  progresses  the  patient's  health  becomes 
much  impaired,  and  at  length  death  ensues  from  exhaustion. 
The  average  duration  of  the  disease  from  beginning  to  end, 
according  to  my  calculation,  is  from  four  to  five  years."* 


S     II. General  Morphology. 

The  initial  lesion  of  mammary  cancer  is  almost  invariably 
a  solitary  nodule ;  the  occasional  origin  of  the  disease  from 
more  than  a  single  primary  focus,  I  have  elsewhere  discussed.^ 
In  very  rare  instances  its  first  obvious  manifestation  is  not 
a  nodule,  but  a  diffuse  infiltration  of  the  whole  of  one  or 
both  glands.  Cancer  may  also  supervene  in  connection  with 
chronic  eczematous  conditions  of  the  nipple  and  areola 
(Paget's  disease).  According  to  Gross  this  happens  only  in 
r3i  per  cent,  of  all  cases.  The  question  of  the  origin  of 
mammary  cancer  from  non-malignant  neoplasms  I  have  fully 
entered  into  elsewhere.^ 

Nearly  all  statistics  show  that  in  women  the  left  breast  is 
more  frequently  affected  than  the  right.  In  151  consecutive 
cases  under  my  observation,  the  left  breast  was  the  seat  of  the 
disease  in  56  per  cent.,  and  the  right  in  44  per  cent.  Of  the 
numerous  cases  collected  by  Gross,  869  were  of  the  left  breast, 
and  793  of  the  right ;  and  in  Billroth's  practice  the  proportion 
was  301  of  the  left  to  279  of  the  right.  In  women  all  other 
mammary  neoplasms  manifest  the  same  predilection  for  the 
left  breast,  but  I  have  not  found  a  similar  disproportion  in 
males.^ 


^  44-8  months  for  the  non-operated  and  6o-8  months  for  the  operated ;  (/.  v.  Ch. 

xiii.  §  I,  sub-section  (/"). 

'Ch.  X.,  §9. 

«  Ch.  X.,  §  10. 

'  "Cancer  of  the  Male  Breast,  based  on  the  records  of  100  Cases,"  Lancet,  vol. 
ii.,  1889,  p.  262.     Right  side,  38  or  53  per  cent.  ;  left,  33  or  47  per  cent. 


154  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

A  very  rare  form  of  initial  outbreak  is  the  simultaneous 
appearance  of  the  disease  in  both  breasts.  Two  instances  of  this 
occurred  in  the  1,664  cases  of  mammary  cancer  collected  by 
Gross. 

Cancerous  tumours  are  more  prone  to  develop  in  some  parts 
of  the  gland  than  in  others.  Its  periphery,  for  instance,  is  a 
much  commoner  seat  of  the  disease  than  its  central  part.  Of 
132  cases  under  my  observation,  in  ninety  (68  per  cent.)  the 
tumour  was  peripheral,  and  in  forty-two  (32  per  cent.)  central. 
This  accords  with  what  I  have  elsewhere  pointed  out  f  that  the 
majority  of  mammary  neoplasms  arise  in  the  seats  of  the  greatest 
post-embryonic  developmental  activity,  where  cells  still  capable 
of  growth  and  development  most  abound ;  that  is  to  say,  in  the 
immediate  vicinity  of  the  acini,  which  are  much  more  numerous 
in  the  peripheral  than  in  the  central  part  of  the  gland. 

Most  of  the  peripheral  tumours  are  met  with  in  the  upper  and 
axillary  mammary  segments.  Thus  in  ninety  cases  under  my 
observation  the  disease  was  situated  in  the  upper  segment  in 
forty-six,  in  the  axillary  in  twenty,  in  the  lozver  in  twenty,  and 
in  the  sternal  in  three.  This  coincides  with  the  results  arrived 
at  by  Winiwarter  and  Gross  :  the  latter's  analysis  of  256  cases 
gives  ninety  for  the  upper,  eighty-three  for  the  axillary,  fifty-one 
for  the  lozver,  and  thirty-two  for  the  sternal  segment. 

A  considerable  number  of  these  peripheral  cancers  are 
situated  quite  outside  the  viainniary  gland,  where,  as  I  have 
shown,  they  originate  from  outlying  sequestrated  mammary 
structures.  This  happened  in  thirteen  (9-8  per  cent.)  out  of  132 
consecutive  breast-cancer  cases  under  my  observation.  Of 
twenty-nine  neoplasms  that  originated  in  this  way,  fifteen  were 
in  situation  axillary,  eight  sternal,  and  six  were  found  above  the 
breast.  As  I  have  elsewhere^  treated  this  important  subject  at 
some  length,  I  need  not  further  allude  to  it  here. 


■*  British  Medical  Jounial,  Sept.  lo,  1892  ;  also  Ch.  vii. 
^'  foiirnal  of  Anatomy,  vul.  xxv. ,  p.  253  ;  alsu  Ch.  iv.,  §  5. 


THE    PRIMARY    NEOPLASM. 


155 


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156             THE    MORPHOLOGY    OF    MAMMARY    CANCER. 
§     III. The  Primary  Neoplasm. 

In  a  typical  case  of  acinous  cancer  the  disease  presents  as 
a  hard  (scirrhus)^*^  nodulated,  heavy,  solid  tumour.  Although 
we  know  from  histology  the  infiltrating  character  of  such  a 
growth,  yet  to  the  unaided  senses  it  generally  seems  to  be  a 
more  or  less  circumscribed  mass  (fig.  28  ^). 

On  careful  examination  of  its  periphery  no  capsule  can  be 
made  out ;  and  it  will  be  seen  that  the  passage  from  the  diseased 
to  the  healthy  tissue  is  by  no  means  sharply  defined — the 
irregularly  growing  edge  of  the  cancer  is,  so  to  speak,  dovetailed 
into  the  surrounding  pre-existing  tissues.  On  this  subject 
Astley  Cooper  remarks  :^^  "  I  would  observe  that  the  scirrhous 
tumour  is  not  all  of  the  disease,  there  are  roots  which  extend  to  a 
considerable  distance,  and  those  who  gave  the  disease  the  name 
of  cancer  probably  knew  more  of  its  nature  than  we  are  disposed 
to  give  them  credit  for.  It  is  supposed  by  some  that  this  name 
was  given  on  account  of  the  appearance  of  the  surrounding 
veins.  I  should  rather  say  it  was  from  the  appearances  on 
dissection  than  from  anything  without.  When  you  dissect  a 
scirrhous  tumour  you  see  a  number  of  roots  proceeding  to  a 
considerable  distance,  and  if  you  remove  the  tumour  only,  and 
not  the  roots,  there  will  be  little  advantage  from  the  operation  " 
(fig.  28  0  and  fig.  29).  This  admirable  resume  of  the  subject  is 
entirely  in  accord  with  the  results  of  modern  research. 

If  we  examine  the  growing  edge  of  a  mammary  cancer  we 
shall  find  that  one  way  in  which  the  disease  progresses  is  by  the 
continuous  centrifugal  extension  of  ingrowing  epithelial  pro- 
cesses (fig.  29).  These  spread  most  rapidly  in  the  directions  of 
least  resistance,  which  are  usually  along  the  adjacent  lymphatics 
and  perivascular  sheaths.     Koster  has  found  these  structures  dis- 

'"  This  term  was  used  by  Galen  {(TKippos,  from  a-Kipos,  a  piece  of  marble)  as 
synonymous  with  SKKvpcDixa — hardness.  It  was  applied  by  him  and  his  successors  to 
all  hard  tumours ;  subsequently  its  application  was  limited  to  indurations  having  a 
special  tendency  to  terminate  in  intractable  ulceration,  and  so  eventually  to  hard 
cancer. 

"   "  Lectures  on  Surgery,"  1839,  p.  386. 


THE    PRIMARY    NEOPLASM. 


0/ 


tended  with  cancer  cells.  Fine,  elongated,  cord-like  processes  of 
cancerous  growth  thus  arise,  which  often  extend  fron:i  the  parent 
tumour  far  into  the  surrounding  tissues,  especially  posteriorly. 
In  this  connection  nodular  growths  often  develop,  which,  to  the 
naked  eye,  may  appear  to  have  no  connection  with  the  primary 
tumour.  In  addition  to  these  there  are  frequently  found  in  the 
vicinity  of  the  latter  really  discontinuous  nodules,  which  are  the 
first  signs  of  regional    dissemination.      Besides  the  foregoing, 


Fig.  29. — Histological  Section  of  Cancer,  showing  the  Roots  {Waldeyer). 
{a)  Epithelial  proliferation  ;  [b)  Invasion  of  stroma  by  the  proliferating  epithelial 
cells. 


small,  discontinuous,  satellite  nodules  are  occasionally  found  in 
the  vicinity  of  the  main  tumour,  which  probably  arise  as  spon- 
taneous outbreaks  of  the  disease  in  outlying  proliferating  acini. 
These  indicate  that  the  tendency  to  cancer  formation  extends 
beyond  the  immediate  limits  of  the  initial  lesion;  and  from  their 
presence  we  may  infer  regional  as  well  as  structural  proclivity. 


158  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

It  will  thus  be  gathered  that  the  integration  of  cancerous 
growths  is  very  inferior  to  that  of  normal  parts.  New  centres 
of  development  are  constantly  arising  among  their  constituent 
proliferating  cells,  so  that  before  the  initial  growth  has  made 
much  progress  numerous  subsidiary  centres  of  morbid  activity 
have  arisen  in  it.  In  this  sense,  as  Virchow^^  has  pointed  out, 
every  cancerous  tumour  is  a  conglomerate  mass  made  up  of  a 
number  of  small  foci,  every  one  of  which,  like  the  initial  tumour 
itself,  may  be  referred  to  a  single,  or  but  a  few  parent  cells. 
Yet,  owing  to  their  infiltrating  mode  of  increase,  sections  of 
mammary  cancers  seldom  present  obvious  signs  of  lobulation. 

The  effect  of  cancerous  growths  on  the  tissues  in  the  midst 
of  which  they  develop  is  to  cause  their  destruction  by  pressure 
atrophy. 

A  crisp,  creaking  sensation  is  experienced  on  making  a 
section  through  such  a  growth,  and  the  cut  surface  "  cups,"  pre- 
senting a  glistening,  whitish,  fibroid  aspect,  interspersed  with 
small,  yellowish,  opaque  spots.  Its  appearance  has  not  inaptly 
been  compared  to  that  of  a  section  of  unripe  pear  {apinoid). 

The  yellowish,  opaque,  granular  areas — most  abundant  at 
the  central  part  of  the  growth — are  due  to  degenerative  changes 
in  the  cancer  cells.  Consequent  shrinkage  of  the  stroma  causes 
the  characteristic  "  cupping."  On  scraping  the  cut  surface  a 
milky  fluid  is  obtained — the  so-called  "  cancer  juice,"  which 
consists  of  polymorphic  epithelial  cells  in  an  albuminous  fluid. 
Irregular  tracts  of  fatty  tissue  can  generally  be  seen  interspersed 
in  the  morbid  mass,  especially  at  its  periphery,  a  peculiarity  not 
met  with  in  any  other  kind  of  mammary  neoplasm.  The  more 
recently  formed  external  parts  of  cancerous  neoplasms  often 
present  a  semi-translucent  appearance. 

Under  the  microscope  sections  of  the  growth  are  seen  to 
consist  of  ovoid  or  irregularly  rounded  masses  of  epithelial  cells, 
enclosed  in  corresponding  alveolar  spaces,  bounded  by  thick 
walls  of  fibrous  tissue  (fig.  30). 

'■•'  *'  Cellular  Pathology,"  Chance's  Translation,  i860,  p.  457. 


THE    PRIMARY    NEOPLASM. 


'59 


In  their  entirety  these  cells  form  solid,  branching,  racemose 
masses,  ingrowing  into  the  surrounding  fibrous  stroma  (fig.  31) 
Such  tumours  increase  in  size  by  the  continuously  progressive 
ingrowing  of  these  budding  epithelial  masses.  Altogether 
the  pathological  appearances  present  striking  resemblance  to 
those  observed  during  certain  stages  of  the  normal  ontogeny  of 
the  organ,  of  which  they  may  be  regarded  as  a  modified  superin- 
duced repetition. 


Fig.  30. — Histological  section  of  hard  mammary   cancer   showing  the    acinous 
grouping  of  the  cells  and  the  alveolar  disposition  of  the  stroma  (JVienu). 


The  factor  underlying  the  progressive  gemmation  of  these 
cell  masses  is  the  continuous  growth  and  proliferation  of  their 
constituent  epithelial  elements.  These  vary  much  in  size  ("Oio 
to  "050  mm.  and  upwards  in  diameter)  and  shape  ;  yet  the 
varieties  met  with  are  not  unparalleled  by  what  is  seen  in  the 
cells  of  the  normal  acini  during  the  various  phases  of  physio- 
logical evolution.  The  cells  of  the  cancer  alveoli  are  evidently 
but  the  slightly  altered  descendants  of  the  secretory  cells  of  the 
gland  ;  hence  their  tendency  to  revert  to  the  parental  type, 
which  is  always   obvious.      The  polymorphism  of  the  cells  of 


i6o 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


acinous  cancer  of  the  breast,  when  not  thus  accountable,  is  simply 
a  pressure  effect,  owing  to  the  rapidly  increasing  cells  being 
cramped  by  the  density  of  the  surrounding  stroma ;  hence  it  is 
seldom  seen,  to  the  same  extent,  in  cancers  of  other  parts. 

The  pathological  cells  multiply,  like  their  physiological  pro- 
totypes, chiefly  by  indirect  nuclear  division  ;  and  the  similarity 
extends  even  to  the  details  of  karyokinesis — equatorial  plates. 


mm  Mc^A'^^^''^''^' 


A 


'0  f^   J  tr     » 


^Ji 


Fig.    31.— Histological   section    through    the    growing   edge   of    the   foregoing 


achromatic  spindles,  &c.  (fig.  32).  Cattle^^  and  others  think,  con- 
sidering the  comparatively  sparse  occurrence  of  nuclear  figures 
in  some  actively  growing  cancers,  that  direct  division  of  cells  is 
extremely  common.  Thus  the  component  cells  of  a  cancerous 
tumour  are  the  direct  descendants  of  the  primary  neoplastic 
cells.  It  has  been  stated  that  the  latter,  by  a  kind  of  sper- 
matic influence,  infect  adjacent  cells,  and  so  excite  in  them 
morbid  action  similar  to  their  own.     This  conception  appears  to 


'■•  "  Ohs.  on  the  Histology  of  Carcinoiiidta  and  the  Parasite-like  Bodies  found  in 
\.\iii\\\'''  Journal  of  Pathology y  Feb.,  1894. 


THE    PRIMARY    NEOPLASM.  l6l 

me  to  be  based  upon  complete  misunderstanding  as  to  the  true 
nature  of  spermatic  influence  ;  and  the  appearances  actually 
observed  afford  it  no  support,  especially  the  comparative 
rarity  of  karyokinetic  figures  in  the  cells  of  the  parablast 
in  the  vicinity  of  active  cancer  growth. 

The  nuclei  of  cancer  cells  are  almost  invariably  much  larger 
than  those  of  the  normal  secretory  cells  of  the  gland ;  they  are 
richer  in  chromatin,  and  they  more  frequently  originate  karyo- 


FiG  32.— Highly  Magnified  Cancer  Cells  showing  Karyokinesis  {Tde). 

{A)  Large,  {B)  small  cell.     The  "■'  plaq7(e  celhilaire"  reticular  filaments,  &c.,  are 
well  shown. 

kinetic  figures  than  the  latter.  A  special  characteristic  of 
cancer  cells,  according  to  Hansemann^^  is,  that  they  divide  by 
asymmetrical  mitoses.  Moreover,  the  pathological  cells,  oftener 
than  their  physiological  prototypes,  contain  more  than  a  single 
nucleus;  and,  as  pointed  out  by  Martin,^^  Cornil,^^  and  others, 
multipolar  nuclear  division  is  of  more  frequent  occurrence  in 
them  than  in  the  normal  cells.  Fabre-Domerguef  maintains 
that  in  proliferating  cancer  cells  the  axis  of  cellular  division 
becomes  displaced  from  its  normal  plane.  Another  peculiarity 
of  cancer  cells,  noticed  by  Shattock  and  Ballance,^''  is  the  prone- 


"  Ueber  path.,  Mitosen.,  Arch.  f.  path.  Anat.,  Bd.  cxxiii.,  Heft.  2,  1891  ;  see 
also  Ueber  asym.  Zelltheilung,  &c.,  Ibid.,  Bd.  cxix.,  Heft  2,  1890. 

'^  Arch.f.  path.  Anat.,  Bd.  Ixxxvi.,  S.  56. 

"^  "  Sur  le  procede  de  division  indirecle  des  noyaux,  &c.,  dans  les  tumeurs,"  Arch, 
de  Physiol.,  1886,  t.  viii.,  p.  310. 

+  C.  R.  Acad,  des  Sci.,  26  mai,   1893. 

"  "  Note  on  the  Histology  of  Sterile,  Incubated,  Cancerous  and  Healthy  Tissues," 
Trans.  Path.  Soc.  Land.,  vol.  xlix.,  1888,  p.  409. 

II 


l62 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


ness  of  their  nuclei  to  shed  their  chromatin  into  the  cell  body, 
&c.,  as  a  sort  of  preliminary  to  division.  Thus  the  so-called 
giant  cells  of  cancer  arise.  Nuclear  fragments  detached  during 
mitotic  changes  probably  originate  the  chromatin  bodies  {corps 
colorables)  described  by  Foa  and  others. 

Taken  in  their  entirety  these  deviations  from  the  normal  are 
but  the  morphological  expressions  of  a  high  degree  of  reproduc- 
tive activity,  which  is  the  essential  characteristic  of  cancer  cells. 
This  phenomenon  seems  to  me  to  be  of  the  same  nature — in 
exaggerated  degree — as  the  accelerated  proliferation  of  epithelial 
cells  noticeable  in  the  process  of  repair  of  wounded  epithelial 
surfaces.     Just  as  this  exceeds  the  physiological  rate  of  increase 


PP-—T^?r' 


Fig.  33. — Mammary  Cancer  Cells  showing  Pseudo-Parasitic 
Endocytes  {Soiidake-Mitch). 

A  and  B,  two  separate  cells;  //,  Pseudo  parasitic  bodies  ;  n.   Nucleus  (Hart- 
nack  Obj.  and  Oc.  No.  3). 


requisite  to  maintain  the  normal  status,  so  the  former  exceeds 
the  latter  ;  but  I  believe  all  these  manifestations  belong  to  the 
same  order  of  events.  The  wonderful  reproductive  activity  of 
cancer  cells  enables  us  to  understand  how  a  single  such  cell  may 
be  the  germ  of  a  large  tumour — even  the  largest.  Only  in  what 
relates  to  this,  do  cancer  cells  differ  from  normal  epithelial  cells. 
In  their  young  state  as  Klebs,  VValdeyer  and  others  have 
observed,  both  possess  contractile  and  locomotive  properties. 

In  addition  to  nuclear  structures  and  their  derivatives,  cancer 
cells  often  contain  certain  rounded  homogeneous,  hyaline,  spore- 
like bodies  (figs.  33  and  34),  which  microscopists  now  are — and 


THE    PRIMARY    NEOPLASM.  1 63 

for  some  time  have  been — exceedingly  busy  in  investigating. 
These  were  first  described  more  than  half-a-century  ago  by  Hake, 
as  parasitic  protozoa ;  and  subsequently  by  Virchow,  who  regarded 
them  as  the  outcome  of  endogenous  cell-formation  and  degenera- 
tive changes.     Now  that  the  subject  has  been  revived  the  contro- 


-J 


'*^^^^^»^ 


Fig.  34.* — A  Highly  Magnified  Cancer  Alveolus  showing  Endocytes 

[Caii/e). 
The   lining   cells   contain  numerous  parasite-like  bodies.     At    a   is   a   dividing 
nucleus.     In  the  large  cell  at  the  left  hand  corner  «  indicates  the  nucleus  and  c  the 
pseudo-parasite,  i  small  round  cell  infiltration  (^  in.  Obj.  Oc.  No.  2). 

versy  still  rages  round  these  rival  views.  Among  recent  workers 
Virchow/^  Noeggerath,^^  Delepine,^^  Edington,^^  Kanthack,^^ 
GibbeSjt  Klebs,  Ribbert,  Cornil,  Stroebe  and  others  maintain 
the  former  view  ;  while  Metschnikoff,^^  Soudakewitch/^  Ruffer/^ 


*  For  this  fine  figure  I  am  indebted  to  Dr.  Cattle,  of  Nottingham,  to  whom  I  here 
tender  my  thanks  for  the  loan  of  his  block. 

'^  "  Bemerkungen  iiber  die  Carcinom-zellen  Einschliisse,"  Arch.  f.  path.  Anat., 
Bd.cxxvii.,  1892,  S.  188. 

"•  Beitr'dge  ziir  Striiktur  und  Entwickelung  des  Carcinoms,  Wiesbaden,  1892. 

20  ((  Protozoa  and  Carcinoma,"  British  Medical  Jonrnal,  vol.  ii.,  1892,  p.  974. 

-'  "  On  a  Form  of  Hyaline  Degeneration,"  Ibid.,  vol.  i.,  1891,  p.  112. 

'--  Ibid.,  vol.  i.,  1891,  p.  579. 

t  Am.  J.  Med.  Sci.,  July,  1893. 

'■"  "  Carcinomata  and  Coccidia,"  Brit.  Med.  Journal,  vol.  ii. ,  1892,  p.  1273. 

-*  "  Des  Parasites  Intra-Cellulaires  des  Neoplasmes  Cancereuses,"  Ajin.  de  rinst, 
Pastetir,  25  mars,  1S92,  p.  145  ;  also  Ibid.,  25  aout,  1892,  p.  545. 

-'"British  Medical  Journal,  vol.  ii.,  1892,  p.  113;  also  Ibid.,  vol.  ii. ,  1S93,  p. 
825. 


164  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

Foa,^^  Pfeiffer,"  Cattle,  Sjobring,  Galloway,  Heukelom  and  others 
uphold  the  latter.  These  bodies  are  usually  most  abundant 
where  there  is  greatest  evidence  of  cellular  activity.  Recently 
abortive  attempts  have  been  made  to  isolate  them  and  cultivate 
them  outside  the  body.^** 

The  following  considerations — inter  alia — appear  to  me  to 
militate  against  their  being  regarded  as  the  specific  cause  of 
cancer:  (i)  Similar  bodies  have  been  observed  in  many  various 
non-cancerous  conditions,  e.g.,  Darier's  disease,  molluscum  conta- 
giosum,  delhi-boil,  rhinoscleroma,  elephantiasis  arabum,  leprosy, 
mycosis    fungoides,   chronic    ulceration,   herpes,    acute    yellow 
atrophy  of  the  liver,  non-malignant  cysts  and  villous  papillomas 
of  the  breast,  villous  papilloma  of  the  bladder,  &c,     (2)  In  un- 
doubted cases  of  human  psorospermosis,  such  as  those  described 
by  Albarran,  Eve  and  Silcock — with  lesions  in  internal  organs — 
these  proved  to  be  cystic  formations,  similar  to  those  found  in 
the    rabbit's    liver,  which    have   no    resemblance    whatever   to 
cancer.     (3)  Before  a  disease  can  properly  be  called  parasitic, 
the  parasite  must  be  found,  isolated,  and  the  disease  it  is  alleged 
to   cause  must  be    reproduced    by  its   inoculation.     It   cannot 
positively  be  affirmed  that  any  of  these  postulates  have  been 
fulfilled  by  the  alleged   cancer   microbe.     Although   the  bodies 
under   discussion    often    look   very   like    parasites,  no    evidence 
has  yet  been   produced  that  they  really  are  such  ;  and,  as  for 
the  other  proofs  required,  they  are  conspicuous  only  by  their 
absence. 

The  presence  of  various,  non-specific,  pathogenic  microbes  in 
cancerous  growths,  has  been  demonstrated  by  Verneuil,  Zahn, 
Hauser,  Schiel,  Nepveu,  Schutz,  and  others.     Verneuil*^  having 


"^  Gaz.  degli  Ospitali,  Feb.  2,  1892.  Lancet,  vol.  i.,  1894,  p.  958.  Gaz.  Med.  di 
Torino,  1891. 

^  "  Die  Prolozoen  als  Krankheitserreger,'"  Jena,  1891  ;  see  also  his  recent  work 
•'  Untersuchungen  Uber  den  Krebs,"  Jena,  1893. 

2«  Lancet,  vol.  i.,  1894,  p.  1232. 

^  Rev.  de  Chir.,  t.  ix.,  10  oct.,  1889.  "  Proprietes  pathogcnes  des  microbes, 
renfermc^'S  dans  les  tumeurs  malignes." 


THE    PRIMARY    NEOPLASM. 


16^ 


noticed  the  frequent  septic  infection  of  operation  wounds  after  the 
removal  of  cancerous  tumours,  was  led  to  examine  the  latter  for 
bacteria ;  and  in  the  softened  areas  he  found  various  kinds  of 
bacilli  and  micrococci  in  abundance.  Zahn/°  by  cultivation 
experiments,  has  shown  that  microbes  abound  in  cancer  meta- 
stases, even  when  the  latter  are  not  in  direct  communication 
with  the  surface  of  the  body.  To  account  for  this,  Hauser^^ 
supposes  that  they  were  carried  there  along  with  cancer  cells 
detached  from  the  primary  focus. 


Fig.  35.— a  Group  of  Cancer  Cells  highly  Magnified  {Ide). 

Showing  the  " ponts  intercellulaires"  and  leucocytes  (/)  which  have  penetrated 
into  the  intercellular  spaces. 


Leucocytes  and  red  blood  corpuscles  have  often  been  detected 
between  closely  approximated  cancer  cells  (iig.  35),  and  even 
within  them.  It  is  easy  to  mistake  cells  of  this  kind  for  para- 
sites, especially  when  they  have  undergone  degenerative  changes. 


^''  Arch.  f.  path.  Anat.,  Bd.  cxvii.,  1889,  S.  37,  and  S.  209. 
^'  "  Das  cylinder  Epitheliom  des  Magens,"  &c. ,  Jena,  1890. 


1 66  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

The  presence  of  leucoytes  between  and  within  cancer  cells  is 
most  noticeable  in  inflamed  areas.  Stroebe^^  maintains  that  this 
indicates  a  kind  of  phagocytosis ;  others  think  it  has  sexual 
significance,  and  they  ascribe  the  abnormal  proliferative  activity 
of  cancer  cells  to  the  effect  of  the  conjugation.  In  the  vicinity 
of  actively  growing  cancer  the  stroma  is  invariably  infiltrated 
with  small,  round,  nucleated  cells. 

It  has  been  demonstrated  by  Ide^^  and  others,  that  the  cells 
of  the  normal  epidermis  and  those  of  cutaneous  epitheliomas, 
possess  a  finely  reticulated  cell  membrane.  Instead  of  being 
completely  isolated,  as  hitherto  believed,  Ide  has  shown  that 
both  the  physiological  and  pathological  cells  communicate  freely 
with  their  neighbours  by  small  bridges — ponts  intercelliilau'es — 
in  which  both  cell  membrane  and  protoplasm  are  involved,  and 
sometimes  even  nuclear  filaments  (fig.  35),  The  cells  of  the 
mammary  epithelium,  being  derivatives  of  the  epidermis,  are 
probably  similarly  related. 

In  cancer  of  the  breast,  however,  the  constituent  epithelial 
cells  usually  hold  together  much  less  firmly  than  do  those  of  the 
normal  gland  ;  in  fact,  they  frequently  seem  to  be  completely 
detached,  and  immersed  in  the  albuminous  fluid  within  the 
alveoli.  This  want  of  cohesion  between  their  constituent  cells, 
is  probably  one  of  the  chief  reasons  why  mammary  cancers 
disseminate  so  much  more  frequently  than  similar  neoplasms 
in  most  other  localities. 

A  remarkable  property  of  the  cells  of  mammary  cancers  is 
their  proneness  to  granulo-fatty  degeneration.  Vacuolation  is 
also  of  common  occurrence.  In  these  respects  they  remind  us 
of  the  similar  metamorphoses  that  the  cells  of  the  normal  gland 
undergo  during  lactation ;  and,  like  the  latter,  they  often  end  in 
complete  disintegration,  with  the  occasional  formation  of  small 
cysts   and    cholesterine    crystals    from    the    debris.     Similarly 


'-   Ueher  Kernthciluii!^  und  Riesenzellenbilduitfi  in  GcscJnoHis/e,  Cs'c,  Jena,  1892, 
■•^  "  NcnivellKS  ubservalion.s  sur  les  cellules  epilheliales,"  La  Cellule,  t.  v.,  1889, 
p.  321. 


THE    I'RIMARY    NEOPLASM.  1 67 

mucoid  secretion  is  sometimes  produced,  which  may  escape 
from  the  nipple,  or  accumulate  within  the  tumour,  and  so  form 
cysts.  This  is  the  nearest  approach  to  normal  secretion  that  the 
pathological  structure  ever  produces.  Very  rarely  the  cells 
undergo  colloid  metamorphosis,  as  in  the  true  colloid  cancers 
and  still  more  rarely  they  calcify,  forming  the  so-called  sand 
grains  (sand-korner^*). 

It  is  chiefly  on  account  of  the  greatly  increased  numbers  of 
the  cells,  and  their  disorderly  grouping,  that  cancer  alveoH  differ 
from  normal  acini.  To  this  may  be  ascribed  the  absence  of 
lumina  and  ducts,  and  the  great  increase  of  size.  It  is,  however, 
a  striking  fact,  that  the  peripheral  cells  of  newly  formed  cancer 
alveoli,  present  well  marked  resemblance  in  shape  and  arrange- 
ment to  the  cells  of  normal  acini.  This  condition,  as  Morton 
has  pointed  out,^^  occasionally  persists;  and  even  distinct 
lumina  may  be  formed.  Another  point  of  resemblance  is  in 
the  distribution  of  the  blood  vessels  and  nerves,  neither  of 
which  are  found  within  cancer  alveoli,  any  more  than  they  are 
within  normal  acini.  The  relations  of  both  to  the  lymphatic 
system  are  also  very  similar;  for,  as  De  Sinety  has  shown, 
within  the  membrana  propria  of  the  normal  acini,  there  exists 
an  imperfect  lining  of  endothelial  cells,  which  is  probably  a 
derivative  of  the  lymphatic  system  ;  and  Cornil  and  Ranvier — 
by  injection  of  Prussian  blue  and  nitrate  of  silver  staining — 
have  demonstrated  that  the  cancer  alveoli  are  in  direct  commu- 
nication with  the  lymphatic  radicles  (fig.  36).  It  is  noteworthy 
that  the  endothelial  cells  of  the  latter  take  no  part  in  the 
cancerous  process. 

From  the  foregoing  we  learn  that  there  is  nothing  specific 
about  cancer  cells  and  structures,  as    was  formerly  believed  ; 


'^  Q.v.  Ackermann,  Arch.  f.  path.  Anaf.,  Bd.  45,  S.  60.  Creighton,  "  Physio- 
logy and  Pathology  of  the  Breast,"  p.  169.  Eve,  Trans.  Path.  Soc.  Load.,  vol. 
xxxvii.,  18S6,  p.  493. 

^^  "  Some  Histological  Conditions  observed  in  Carcinoma  of  the  Breast,"  British 
Medical  Journal,  vol.  ii. ,  1892,  p.  676. 


1 68 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


there  is  departure  from  the  normal  type  of  development,  but  no 
foreign  structures  are  produced. 

The  stroma  of  mammary  cancers  forms  the  fibrous  alveolar 
system,  in  the  meshes  of  which  the  proliferating  epithelial  cells 
are  confined  (figs.  30  and  31).  Alveolar  disposition  of  the 
stroma  was  formerly  regarded  as  the  histological  criterion  of 
cancer ;  but  it  is  now  known  to  be  merely  a  local  peculiarity. 
In    most    acute    mammary    cancers    alveolar    arrangement   is 


-v^ 


Fig.  36. — Cancer  Alveoli  and  the  Lymphatic  Radicles 
(Cornil and  Ranvier). 

Histological  section  of  mammary  cancer  stained  with  nitrate  of  silver  ;  (a) 
Cancer  alveoli  with  their  contained  cells  ;  {b)  Stromal  tissue  showing  the  deeply 
stained  cell  spaces.  To  the  right  the  endothelial  lining  cells  of  a  lymphatic  radicle 
are  similarly  displayed  (  x    150  dia. ). 


wanting,  the  cells  being  diffused,  often  in  single  rows,  between 
the  fibrils  of  the  stroma.  In  its  minute  structure  and  general 
characters,  the  cancer  stroma  closely  resembles  the  stroma  of 
the  normal  gland,  of  which  it  is  evidently  a  derivative.  It 
consists  of  thick  bands  of  dense  white  fibrous  tissue,  containing 
elastic  fibres,  and  anastomosing  connective  tissue  cells,  which 
are  especially  numerous  at  the  meeting  points  of  the  diverging 


THE    PRIMARY    NEOPLASM.  1 69 

bands.  The  characteristic  hardness  of  mammary  cancers  is  due 
to  its  abundance  and  density.  The  question  has  been  much 
discussed  whether  the  cancer  stroma  is  of  new  formation,  or 
simply  the  modified  pre-existing  structure.  It  seems  almost 
certain,  from  its  great  abundance,  and  from  other  considerations, 
that  it  is  largely  of  new  formation.  Coincidently  with  the 
initial  proliferation  of  the  cells  within  the  pathological  acinus, 
there  appears  an  infiltration  of  the  periacinous  connective  tissue 
with  small  round  cells.  It  is  from  this  embryonic  parablastic 
tissue  that  the  newly-formed  cancer  stroma  is  chiefly  developed. 
The  constant  presence  of  these  cells  in  the  stroma  of  mammary 
cancers  is  an  important  factor.  By  some  pathologists  they  are 
regarded  merely  as  leucocytes,  derived  from  the  blood  vessels  of 
the  stroma,  as  the  result  of  chronic  inflammation  ;  but  from  their 
periacinous  grouping  it  is  more  probable  that  most  of  them 
arise  as  the  outcome  of  the  developmental  rather  than  of  the 
inflammatory  process.  They  consist  mainly  of  nuclear  sub- 
stance. Their  presence  in  the  cancer  stroma  indicates  that  the 
latter  is  an  imperfect  formation.  An  extreme  degree  of  the 
same  condition  is  seen  when  the  stroma  does  not  evolve  beyond 
the  myxomatous  stage,  as  in  the  rare  variety  of  the  disease 
called  carcinoma  myxomatodes.  In  like  manner,  the  presence  of 
spindle  cells  in  the  stroma  may  be  explained.  Hansemann,^^ 
who  has  lately  made  special  study  of  the  cells  in  the  cancer 
stroma,  describes  four  different  kinds:  (i)  Fusiform  and  stellate 
cells,  the  ordinary  connective  tissue  cells.  (2)  Flattened  epithe- 
loid  cells  arranged  around  the  walls  of  the  lymphatic  canaliculi. 
(3)  Cells  with  large  deeply  staining  nuclei  and  little  protoplasm 
— lymphocytes.  (4)  Cells  with  lobulated  or  budding  nuclei — leu- 
cocytes— emigrant  white  blood  corpuscles.  He  has  often  met 
with  mitotic  figures  in  connection  with  the  multiplication  of 
these  cells. 

Inasmuch  as  there  may  occasionally  be  found  in  the  stroma 
of  the  otherwise  normal  gland,  small  cartilaginous,  calcareous, 

•'"  Anh.f.  path.  Anat.,  Bd.  cxxxiii.,  1893,  S.   147. 


170  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

and  even  truly  osseous  nodules,  it  need  not  surprise  us  that  now 
and  then  similar  conditions  are  found  associated  with  cancers,^'^ 
and  other  mammary  neoplasms.^'^  In  the  Himterian  Miiseumf 
there  are  some  specimens  by  Astley  Cooper,  showing  calcareous 
deposits — chiefly  periductal — in  cancerous  breasts. 
The  following  case  by  Heurtaux  is  remarkable : — 

A  woman,  aged  52,  eight  months  previously  received  a  slight  blow  on 
the  left  breast  ;  two  months  afterwards  she  noticed  a  small,  hard  tumour  in 
the  organ,  which  gradually  increased.  On  examination,  there  presented  in 
the  left  breast  a  tumour  the  size  of  a  small  orange.  It  was  circumscribed, 
mobile,  nodulated,  and  very  hard  ;  no  retraction  of  the  nipple,  but  slight 
adhesions  with  the  deep  part  of  the  overlying  skin  ;  the  overlying  cutaneous 
veins  distended  ;  no  enlargement  of  the  axillary  glands.  Amputation  of  the 
breast.  On  attempting  to  make  a  section  of  the  tumour,  it  seemed  to  be 
composed  of  a  substance  like  cancellous  bone.  Closer  examination  revealed 
a  lardaceous,  scirrhus  structure  with  osteoid  areas.  On  histological  examina- 
tion, the  scirrhus  structure  consisted  of  ordinary  alveolar  cancer  with  which 
were  intermixed  small  areas  of  cartilagittous  tissue.  The  osteoid  areas, 
although  not  presenting  all  the  characters  of  fully  formed  bone,  seemed 
to  have  resulted  from  imperfect  ossification  of  the  cartilaginous  depots. 
Three  months  after  operation,  two  extremely  hard  tumours  appeared  in 
the  axilla,  and  increased  very  rapidly,  and  other  nodules  sprang  up.  These 
were  of  stony  hardness,  just  like  the  primary  tumour.  Health  rapidly 
deteriorated,  and  symptoms  developed  as  of  secondary  growths  in  the  lungs. 
She  died  thus  of  asthenia  eight  months  after  the  first  appearance  of  the 
recurrent  disease. 

Within  the  cancer  stroma  numerous  small  arteries,  veins,  and 
capillaries  ramify,  most  of  which  are  derivatives  of  the  pre- 
existing vessels.  They  have  been  injected  by  Thiersch,  Billroth, 
and  others,  and  found  to  form  networks  of  similar  form  to  the 
alveoli.  They  are  generally  larger  and  less  regular  in  their 
calibre  and  arrangement  than  the  corresponding  normal  blood- 
vessels, tortuous  dilatations  and  small  saculations  being  of 
frequent  occurrence.  According  to  Quenu,  their  walls  arc  often 
thickened,  and  their  lumina  occluded,  in  consequence  of  chronic 


''  Coen,  Condro-osleo-carcinoma  delta  Mammella  Muliebre,  Bologna,  1891. 
Heurtaux  "Cancer  osteoide  du  Sein,"  Mem  de  la  Soc.  de  C/iir.,t.  vii.,  p.  i.,  Hacker, 
Arch.f.  klin.  Chir.,  Bd.  xxvii.,  S.  614,  Warren,  "Surg.  Obs.  on  Tumours,"  Boston, 
p.  213. 

•''*  Billroth,  Die  Krankheitcn  der  Brustdrilsen,  1880,  S.  48,  &c. 

*  Path.  Catalogue,  Nos.  4747  A,  B,  and  C. 


THE    PRIMARY    NEOPLASM.  17I 

endarteritis.  These  lesions  are  occasionally  so  marked  as  to 
produce  a  telangeiectatic  condition.  While  the  vascular  system 
of  cancers  can  be  readily  injected  by  the  arteries — even  the 
smallest — it  is  generally  difficult  to  do  so  by  the  veins,  the 
substance  injected  then  finding  its  way  into  the  circumferential 
venous  system,  instead  of  into  that  of  the  neoplasm.  This  is 
probably  due  to  the  frequent  blocking  of  the  veins  by  the  growth 
of  the  neoplasm,  by  thrombi,  &c.  Thus  may  be  explained  the 
venous  engorgement — often  obvious  through  the  overlying  skin 
— that  is  almost  invariably  associated  with  mammary  cancer. 

Accompanying  the  stromal  blood  vessels  are  numerous 
lymphatics,  which  have  been  injected,  and  their  distribution 
studied  by  Schroeder  van  der  Kolk,  Krause,  Rindfleisch,  and 
others.  Their  radicles,  as  previously  mentioned,  are  in  direct 
communication  with  the  cancer  alveoli.  This  explains  the 
great  frequency  of  dissemination  in  the  lymphatic  glands. 

Cancers  are  generally  regarded  as  nerveless,  but  vaso-motor 
filaments  probably  accompany  the  stromal  blood  vessels, 
although  this  is  denied  by  Verneuil  and  Nepveu.  Our  know- 
ledge of  this  subject  is  singularly  inadequate,  and  there  is 
here  great  need  of  further  investigation. 

The  chemical  analysis  of  cancerous  growths — much  neglected 
of  late — has  hitherto  failed  to  reveal  the  presence  of  any  specific 
morbid  substance.^*^  Albuminous  constituents  predominate. 
Beneke  has  found  an  abundance  of  myeline  and  cholesterine. 
According  to  Freund,  sugar  and  glycogen  are  invariably 
present.  The  reaction  of  the  juice  of  fresh  mammary  cancers 
has  been  in  dispute  for  the  last  half  century,  and  the  state- 
ments of  different  observers  now  are  just  as  conflicting  as 
they  ever  were.     According  to  the  latest  experiments,*^  the  juice 


^"  Adamkiewicz  {Untersiichungen  fiber  den  Krebs,  &c.,  Vien.,  1893)  alleges  that 
he  has  discovered  such  a  substance,  which  he  calls  "cancroin"  ;  and  he  claims  to 
have  cured  many  cancers  by  injecting  it  subcutaneously.  According  to  A.  the  con- 
stituent cells  of  cancers  are  not  epithelial  cells,  but  parasitic  organisms  (coccidium 
sarcolytus). 

"  Lancet,  vol.  i.,  1894,  p.  1232. 


172  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

of  perfectly  fresh  mammary  cancer  is  of  alkaline  or  neutral 
reaction  ;  whereas  within  a  few  hours  after  death  the  reaction 
has  become  acid.  Waring*^  has  lately  demonstrated  the  highly 
important  fact  that  the  constituent  cells  of  cancers  of  the  pan- 
creas and  stomach  produce  the  same  ferments — trypsin,  pepsin, 
&c. — as  the  normal  secretory  cells  and  these  organs.  Since  the 
above  was  written  I  have  seen  a  report  of  some  recent  investiga- 
tions by  Hewlett*  whence  he  concludes ;  that  the  cells  in  cancer, 
sarcoma,  and  adenoma  contain  about  the  same  amount  of 
phosphorus  as  those  of  the  normal  tissues  ;  that  there  is  no 
special  distribution  of  iron  in  these  tumours,  their  cells  being 
neither  richer  nor  poorer  in  this  respect  than  the  ordinary  tissue 
cells  ;  and  that  the  proteids  of  cancer,  like  those  of  other  cellular 
organs,  consist  chiefly  of  neucleo-albumin.  As  to  the  presence 
of  albumoses  in  cancerous  tissue  and  their  alleged  tendency  to 
accumulate  in  the  spleen,  these  questions  are  still  sub  judice. 

In  many  parts  of  the  body,  such  as  the  buccal  cavity,  the 
outbreak  of  cancer  is  commonly  preceded  by  obvious  hyper- 
plastic changes  (ichthyosis)  in  the  surface  epithelia.  Moreover, 
it  is  noticeable  that  these  lesions  are  seldom  limited  to  the 
precise  starting-point  of  the  cancerous  disease.  This  clearly 
implies  that  the  abnormal  activity,  which  at  a  given  spot 
culminates  in  cancer,  affects  in  a  less  degree  the  adjacent 
epithelia  of  the  region  for  a  considerable  extent.  The  ques- 
tion arises  whether  all  parts  of  the  body,  in  which  cancers 
arise,  are  not  similarly  circumstanced.  The  indications  at 
present  forthcoming  are  decidedly  in  favour  of  an  affirmative 
answer ;  the  admirable  researches  of  Heidenhain^^  have,  at  any 
rate,  answered  the  question  in  this  sense  for  the  female  breast. 
He  has   conclusively  shown   that  every   mamma  containing  a 


^"^  Journal  of  Anatomy,  Oct.,  1893,  p.  142.  "The  Physiological  Characters  of 
Carcinomala. " 

*  Brit.  Med.  fournal,  vol.  ii.,  1894,  p.  190. 

"  Arch.  f.  klin.  Chir.,  Bd.,  xxxix.,  1889,  S.  97.  Heidenhain's  results  have  been 
fully  confirmed  by  the  observations  of  Messrs.  Johnson  and  Beadles.  Trans.  Path. 
Soc,  Lond.,  1892. 


THE    PRIMARY    NEOPLASM.  1 73 

cancerous  tumour  is  diseased  throughout.  Its  secretory  cells 
are  unduly  numerous,  and  they  everywhere  show  signs  of 
excessive  reproductive  activity ;  while  the  periacinous  con- 
nective tissue  is  much  increased,  its  nuclei  are  unduly  abundant 
and  it  is  infiltrated  with  small  round  cells.  It  is  a  legitimate 
inference,  that  parts  in  such  a  condition  are  more  prone  to 
originate  cancer  than  perfectly  normal  structures.  Heidenhain 
is  no  doubt  right  in  maintaining  that  proliferating  acini  of  this 
kind,  left  behind  at  the  primary  operation,  are  the  germs  whence 
most  late  recurrences  arise. 

He  has  also  shown  that  the  loose  areolar  tissue  intervening 
between  the  mammary  gland  and  the  pectoralis  major  muscle, 
contains  numerous  glandular  offshoots  and  lymphatics,  which 
in  cancer  cases  are  nearly  always  diseased.  Some  of  these  not 
only  adhere  to  the  fascia  over  the  muscle,  but  often  penetrate  it, 
and  even  become  embedded  in  the  muscle  itself.  In  the  ordinary 
operation  of  amputation  of  the  breast,  these  structures  are 
almost  invariably  cut  off  and  left  behind.  On  careful  examina- 
tion after  removal,  Heidenhain  found  that  the  disease  had  not 
been  completely  extirpated  from  this  situation  in  twelve  out  of 
eighteen  breasts  consecutively  amputated  for  cancer,  and  he 
predicted  recurrences,  which  soon  followed.  To  obviate  this  he 
recommends  that  the  fascia  over  the  pectoj'alis  major  muscle,  and 
a  layer  of  the  subjacent  muscular  substance,  should  be  removed 
in  every  case,  together  with  the  diseased  breast;  and  I  certainly 
think  this  recommendation  ought  to  be  regarded  as  an  essential 
feature  of  the  operation. 

Stiles^*  has  lately  devised  a  method  for  determining,  without 
microscopical  examination,  whether  the  whole  of  the  cancerous 
growth  and  glandular  tissue  have  been  removed  or  not.  The 
breast  is  first  freed  from  blood  by  immersion  in  running  water; 
it  is  then  submerged  (whole  or  sliced)  for  about  ten  minutes  in  a 
quart  of  five  per.  cent  aqueous  solution  of  acidum  nitricuni^  B.P., 


■'•'  "Contribution  to  the  Surgical  Anatomy  of  the  Breast,"  Edinburoh  Medical 
Journal,  June,  1892. 


174  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

and  then  washed  again  for  a  few  minutes,  after  which  it  is  placed 
in  undiluted  methylated  spirit.  By  this  method  the  highly 
albuminous  epithelial  cells  are  converted  into  a  dull,  greyish- 
white  opaque  substance,  which  can  be  readily  distinguished  from 
the  more  translucent  stroma.  From  the  arrangement  of  the 
opaque  epithelial  areas  their  cancerous  or  non-cancerous  nature 
can  generally  be  determined.  In  this  way  the  relations  of  the 
neoplasm  to  the  gland,  its  exact  limits,  and  the  mode  and  extent 
of  its  infiltrations  can  be  definitely  ascertained. 

As  the  result  of  the  extensive  application  of  this  method, 
Stiles,  like  Heidenhain,  has  found  that  the  disease  is  very  seldom 
completely  extirpated  by  the  ordinary  operative  proceedings 
hitherto  in  vogue.  He  has  especially  pointed  out  the  facility  with 
which  the  skin  over  cancerous  growths  becomes  affected,  owing 
to  its  connection  with  the  ligamenta  suspensoria  of  Cooper,  and 
their  contained  glandular  processes,  lymphatics,  &c.,  along  which 
the  disease  readily  spreads]  (fig.  28). 

S     IV. Local  Dissemination. 

Waldeyer,  from  the  histological  standpoint,  has  defined 
cancer  as  "  a-typical,  epithelial  proliferation  ; "  but  the  researches 
of  Wyss,*^  Friedlander*''  and  others,  have  shown  that  this  defini- 
tion does  not  suffice.  They  have  found  atypical  epithelial  in- 
growths common  enough  in  many  chronic  inflammatory  pro- 
cesses, affecting  epithelial-covered  surfaces.  One  of  the  best 
examples  is  furnished  by  the  so-called  "  erosions"  of  the  ostiteri ; 
in  this  condition  newly-formed  structures  abound  exactly  like 
cancer  structures.  To  the  above  definition,  therefore,  it  must  be 
added,  that  the  proliferation  is  of  a  malignant  nature,  and  this  is 
its  essential  feature.  In  accepting  this  definition  we  abandon 
the  field  of  histology,  for  histological  analysis  cannot  furnish  a 
criterion  of  malignancy.     I  have  observed  that  much  confusion 


*'-  Arch.  f.  path.  A>ia/.,  Bd.  Ixix.,  .S.  24. 

**  Uiber  EpHhelwuiherinii;  2ind  Krebs,  Slrassburg,  1877. 


LOCAL    DISSEMINATION.  175 

exists  as  to  the  precise  meaning  of  this  term — malignancy.  It 
is  commonly  used  as  synonymous  with  disseminative^  whereas 
these  two  properties  of  certain  neoplasms,  although  they  usually 
go  together,  are  in  reality  quite  distinct.  The  term  malignancy 
is  by  me  applied  to  the  remarkable  inherent  power  possessed  by 
certain  neoplasms  of  contimions  iindiie  increase,  owing  to  the 
indefinitely  sustained,  excessive  proliferative  activity  of  their 
constituent  cells.  In  this  sense  all  cancers  are  malignant.  The 
disseminativeness  of  certain  neoplasms,  on  the  other  hand,  is 
largely  of  the  nature  of  an  accidental  occurrence  ;  that  is  to  say, 
it  is  chiefly  dependent  upon  local  structural  peculiarities,  which 
render  it  easy  for  the  constituent  proliferous  cells  to  get  access 
to  and  to  be  transported  by  the  adjacent  lymphatics  and  blood- 
vessels. This  explains  the  great  variability  in  the  degree  of 
disseminativeness  that  is  so  frequently  witnessed.  Cancers  are 
usually  disseminative  as  well  as  malignant  ;  yet,  when  the  local 
conditions  are  unfavourable,  as  in  rodent  ulcer  and  some  tubular 
cancers  of  the  breast,  we  get  malignancy  without  dissemination. 

That  mammary  cancers  are  so  very  commonly  disseminative 
is  mainly  due  to  the  great  abundance  of  the  lymphatics  and 
blood-vessels  of  the  breast,  and  to  the  close  relationship  obtain- 
ing between  these — especially  the  lymphatics — and  the  cancer 
cells,  as  well  as  to  the  feeble  cohesion  existing  between  the 
latter. 

As  previously  mentioned,  at  an  early  stage  of  the  disease, 
there  may  frequently  be  found  in  the  vicinity  of  the  primary 
neoplasm,  really  discontinuous  satellite  nodules,  which  are  the 
first  signs  of  regional  dissemination.**''  These  arise,  as  Langhans, 
Waldeyer  and  others  have  shown,  from  cellular  elements 
detached  from  the  primary  tumour,  and  conveyed  to  their  new 
destination  by  the  lymphatics  or  veins,  or  by  their  own  sponta- 
neous movements. 

In  mammary  cancer  the  tendency  to  local  dissemination  is 


■"  Q.v.  Leopold,  Arch.  f.  Gyn.,  Bd.  v.,  S.  405. 


176  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

very  marked.  Torok  and  Wittelshofer,^^  basing  their  observa- 
ions  on  2^66  post-uiortem  examinations,  met  with  it  in  about  52 
per  cent,  of  all  cases.  They  found  nodules  in  the  skin  in  10  per 
cent.,  in  the  para-mammary  fatty  tissue  in  8  per  cent.,  in  the 
pectoral  muscles  in  16  per  cent.,  in  the  intercostals  in  6  per  cent., 
in  the  ribs  in  8  per  cent.,  in  the  sternum  in  5  per  cent.,  in  the 
clavicle  in  8  per  cent.,  in  the  pleura  and  lungs  in  6'?>  per  cent.,  in 
the  pericardium  in  "54  per  cent.,  and  in  the  opposite  breast  in  9 
per  cent. 

With  regard  to  the  last  named  condition,  it  is  not  so  very 
rare  for  cancer  of  one  breast  to  be  followed  after  a  time  by  out- 
break of  the  disease  in  the  other.  This  occurred  in  eight  of  the 
forty-four  necropsies  in  my  list,  or  in  iS'i  per  cent.  According 
to  Gross  it  is  a  late  symptom,  not  supervening  on  the  average 
until  29*8  months  after  the  onset  of  the  primary  disease.  Of 
nine  such  cases  under  my  observation  four  were  due  to  lymphatic 
dissemination,  three  to  direct  extension,  one  to  metastasis  and 
one  to  multiple  origin. 

Subjoined  is  a  short  account  of  the  cases  due  to  lymphatic 
dissemination^ 

(i)  A  widow,  aged  76,  twenty  years  ago  noticed  a  small  hard  can- 
cerous nodule  in  her  left  breast,  beneath  the  nipple.  Ten  months  ago  she 
found  a  similar  lump  in  the  upper  part  of  her  right  breast.  No  operation 
had  ever  been  done.  When  I  first  saw  her  she  was  pale,  sallow  and 
emaciated.  The  breasts  were  small  and  wasted.  A  hard,  irregular,  can- 
cerous ulcer  rather  larger  than  the  palm  of  the  hand,  occupied  the  left 
mammary  region  ;  and  was  fi.xed  to  the  subjacent  tissues.  There  was  a 
smallei;  cancerous  ulcer  of  similar  nature  at  the  upper  part  of  the  right 
breast.  The  glands  of  the  left  axilla  and  those  above  the  left  clavicle  were 
obviously  affected. 

(2)  A  single  woman,  aged  65,  six  years  ago  noticed  a  small,  hard,  can- 
cerous tumour  at  the  lower  and  outer  part  of  her  7-ight  breast.  Four  years 
later  the  diseased  part  was  amputated.  One  year  later  there  was  recurrence 
in  the  chest  and  axilla.  Six  months  later  a  hard  lump  was  first  noticed  at 
the  inner  part  of  the  left  breast  and  in  the  left  axilla.  When  I  first  saw  her 
she  was  emaciated  and  sallow.  Across  the  right  mammary  region,  in  the 
seat  of  the  operation  scar,  was  a  hard,  elongated,  cancerous  ulcer  ;  and  at 
the  inner  edge  of  the  left  breast  a  hard,  nodular,  cancerous  growth,  the  size 

«  Arch.f.  klin.  Chir.,  Bd.  xxv.,  i88i,  S.  873. 


LOCAL    DISSEMINATION.  I  ^"J 

of  a  hazel  nut.  The  glands  of  both  axiike  were  enlarged  and  hard.  She 
died  of  asthenia  fifty  days  later.  At  the  Jiecropsy  the  ulcerated  cancerous 
growth  in  the  right  mammary  region  was  found  to  have  penetrated  the  entire 
thickness  of  the  pectoral  muscle  and  to  have  infiltrated  the  sixth  rib.  The 
spleen  contained  eight  small  secondary  nodules  on  its  surface.  There  was 
double  emphysema  and  bronchitis,  with  old  pleural  adhesions.  Liver  and 
heart  fatty.  Double  chronic  interstitial  nephritis.  Left  femoral  hernial  sac, 
containing  omentum. 

(3)  A  multipara,  aged  46,  in  the  middle  of  whose  rigid  breast  a 
cancerous  tumour,  the  size  of  a  walnut,  first  appeared  three  and  a-half  years 
ago.  One  year  later  the  part  was  amputated.  Six  months  ago  the  disease 
returned  in  situ^  and  soon  afterwards  she  noticed  a  lump  the  size  of  a  walnut 
in  the  middle  of  her  left  breast.  When  I  saw  her  she  was  pale  and  rather 
sallow.  Surrounding  the  puckered  operation  scar  were  numerous  small, 
hard,  recurrent  nodules,  many  of  them  eroded.  In  the  left  breast  was  a 
hard  lump,  the  size  of  a  hen's  &gg^  adherent  to  the  overlying  nipple,  which 
was  retracted,  but  mobile  on  the  chest  wall.  The  glands  of  both  axillae 
enlarged,  as  well  as  some  of  those  above  the  right  clavicle.  A  year  later  this 
patient  again  came  under  my  notice,  when  I  found  the  skin  of  the  whole  of 
the  front  of  the  chest  and  the  upper  half  of  the  abdomen  thickly  studded  with 
small,  flat  discs  of  hard  cancer — mostly  discrete,  but  here  and  there  con- 
fluent. Many  of  them  were  eroded.  On  the  right  side  of  the  chest  this 
condition  extended  back  as  far  as  the  scapula.  The  right  upper  limb  was 
much  swollen  from  oedema.  In  addition  to  the  glands  previously  mentioned 
as  affected,  those  of  both  groins  were  also  invaded.  She  died  of  asthenia 
nineteen  days  later.  At  the  7iecropsy  the  right  side  the  chest  wall  was  deeply 
invaded  over  a  wide  area  by  dense,  white,  fibroid  new  growth.  The  right 
pleura  was  infiltrated  by  direct  extension.  At  its  lower  part  was  a  localised 
suppurative  focus.  No  other  internal  cancerous  lesions.  Extreme  stenosis 
of  the  mitral  and  tricuspid  orifices.  Atheroma  of  aortic  arch.  Liver  fatty. 
Double  chronic  interstitial  nephritis.  Numerous  small  uric  acid  calculi  in 
pelvis  of  left  kidney,  and  similar  gravel  in  pelvis  of  right  kidney. 

(4)  A  sterile  married  woman,  aged  50,  six  months  ago  noticed  ill-defined 
hardness  at  the  middle  of  her  r^^/?/ breast.  When  seen  by  me  she  was  stout 
and  healthy  looking.  The  right  mammary  region  was  occupied  by  a  hard, 
projecting  mass  of  new  growth,  the  size  of  the  foetal  head  at  birth.  This 
mass  was  movable  on  the  subjacent  parts,  but  adherent  to  the  over-lying 
skin.  The  nipple  was  retracted,  and  there  was  an  enlarged  gland  in  the 
right  axilla.  No  operation  was  done.  She  died  of  asthenia  two  and  a-half 
months  later.  At  the  necropsy  the  body  was  pale,  emaciated,  and  sallow. 
Each  breast  was  occupied  by  a  large  mass  of  hard,  cancerous  growth,  to 
which  the  overlying  skin  was  adherent  and  ulcerated.  On  the  right  side  the 
muscles  and  bones  of  the  chest  wall  were  infiltrated.  The  skin  of  the  front 
of  the  chest  was  thickly  studded  with  small,  hard  nodules,  some  of  them 
eroded.  The  axillary  glands  of  both  sides  were  infiltrated.  The  liver  con- 
tained several  firm,  whitish,  cancerous  nodules. 


12 


178 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


The  three  following  cases  illustrate  the  invasion  of  the 
opposite  breast  by  direct  extension. 

(i)  Three  years  ago  a  multipara,  aged  45,  first  noticed  a  cancerous  lump 
in  her  ris^ht  breast  above  the  nipple,  and  an  enlarged  glan'd  in  the  axilla. 
No  operation.  On  examination  I  found  several  hard,  cancerous  nodules  in 
the  right  breast,  and  the  skin  of  the  right  pectoral,  axillary,  and  left  mammary 
regions  infiltrated  '^  en  adrasse."  The  right  axillary  glands  were  infiltrated, 
and  the  upper  limb  of  this  side  was  cedematous.  She  died  of  pulmonary 
complications,  &c.,  forty-two  days  later.  At  the  necropsy  a  mass  of  hard 
cancer,  the  size  of  an  orange,  occupied  the  right  mammary  region.  There 
was  extensive  cuirassed  infiltration  of  the  skin  of  the  front  of  the  chest  on 
both  sides.  The  glands  in  both  axillae  were  cancerous.  Both  lungs  and 
bronchial  glands  contained  secondary  cancerous  growths. 

(2)  A  woman,  aged  38,  the  mother  of  three  children,  seven  years  ago 
noticed  a  lump  the  size  of  a  hazel  nut  in  the  upper  part  of  the  periphery  of 
her  left  breast.  Four  and  half  years  later  she  also  noticed  a  lump  in  the 
axilla.  Six  months  later  the  breast  was  amputated,  and  the  axilla  cleared. 
One  year  afterwards  a  recurrent  nodule  appeared  at  the  middle  of  the 
mammary  scar.  When  I  saw  her  the  whole  of  the  space  between  this  scar 
and  the  clavicle  and  the  parts  for  a  few  inches  below  the  scar,  were  invaded 
by  hard,  nodular,  cancerous  growth,  which  was  firmly  fixed  to  the  chest  wall. 
The  overlying  skin  was  adherent,  infiltrated  and  purplish.  The  infiltration 
had  crossed  the  median  line  of  the  body,  and  had  begun  to  encroach  on  the 
right  breast.  The  left  axilla  was  invaded  by  cancerous  infiltration,  as  also 
were  the  glands  at  the  root  of  the  neck.  The  upper  limb  on  this  side  was 
cedematous.  In  the  right  axilla  was  a  cancerous  lump  the  size  of  a  walnut. 
She  died  of  hydrothorax  and  pulmonary  collapse,  eighty-one  days  later.  At 
the  necropsy  the  entire  thickness  of  tissues  of  the  left  pectoral  region  invaded 
by  dense  cancerous  growth,  which  had  perforated  them  and  spread  to  the 
lung  and  anterior  mediastinum,  and  thence  to  the  root  of  the  left  lung,  where, 
by  compressing  the  pulmonary  veins,  it  had  caused  extreme  hydrothorax  and 
collapse  of  the  lung  ;  five  pints  of  clear  serous  fluid  were  removed  from  this 
pleura.  The  left  axillary  vein  had  been  compressed  by  a  mass  of  cancerous 
glands  there.  Secondary  cancerous  growths  in  the  left  supra-renal  body, 
both  kidneys  and  the  left  ovary. 

(3)  The  primary  disease  in  the  left  breast  was  first  noticed  two  years  ago. 
Three  months  later  the  breast  was  amputated  and  the  axilla  cleared.  Six 
months  afterwards  recurrence  in  the  chest  and  axilla  set  in.  On  examination 
I  found  the  whole  of  the  tissues  of  the  upper  part  of  the  chest  on  the  left 
side,  the  shoulder  and  the  arm,  infiltrated  by  hard,  cuirassed  cancer,  which 
in  the  subsequent  progress  of  the  disease  crossed  the  middle  of  the  body  and 
invaded  the  opposite  breast.  Both  axillary  glands  were  infiltrated.  She 
died  from  invasion  of  the  left  lung  and  pericardium  by  direct  extension  of 
the  disease  through  the  chest  wall.  The  ribs  were  infihratcd,  and  there 
were  secondary  growths  in  the  liver  and  peritoneum. 

In   certain  rare  cases  of  irregular  lynnphatic  dissemination 


LYMPH    GLAND    DISSEMINATION.  1 79 

the  disease  may  be  conveyed  to  the  larg-e  nerve  cords  of  the 
axilla/*  to  the  upper  end  of  the  humerus, ^°  to  the  retro-sternal 
tissues,  &c. 

Local  dissemination  has  an  important  bearing  when  the 
question  of  operation  is  under  consideration,  for  it  appears  from 
the  following  considerations,  that  the  spread  of  the  disease  to 
the  lymphatic  glands  and  to  the  system  generally,  is  greatly 
favoured  by  local  dissemination.  Thus,  of  192  cases  with  local 
dissemination,  Torok  and  Wittelshofer  found  the  lymphatic 
glands  invaded  in  52'6  per  cent.,  and  metastases  in  72*9  per 
cent.;  whereas  of  174  cases  free  from  local  dissemination,  the 
lymphatic  glands  were  affected  only  in  42'5  per  cent.,  and  there 
were  metatases  in  but  45*4  per  cent. 

In  structure,  these  local  disseminative  nodules  are  identical 
with  the  primary  tumour  whence  they  originate  ;  and  they  Con- 
stitute fresh  centres  of  the  disease,  which  progress  precisely  as 
the  latter. 

S     V  . Lymph  Gland  Dissemination. 

One  of  the  earliest  consequences  of  the  development  of  a 
cancerous  tumour  in  the  breast  is  that  the  adjacent  axillary 
lymph  glands  become  enlarged.  This  condition  may  be  only 
transitory,  as  in  the  glandular  enlargements  occasionally  seen  in 
the  course  of  most  infectious  diseases,  in  association  with  non- 
malignant  mammary  tumours,  and  in  the  axillary  glands  left 
behind  after  amputation  of  the  breast.  Such  enlargements  are 
usually  ascribed  to  "irritation"  or  "chronic  inflammation." 
Histological  examination  reveals  nothing  more  than  undue 
increase  in  number  and  size  of  the  lymphoid  cells,  together 
with  thickening  of  the  fibrous  reticulum,  and  proliferation  of 
its  nuclei,  as  well  as  hyperplasia  of  the  endothelia.  These 
changes  cause  obstruction  of  the  lymph  sinuses  ;  and  conse- 
quent clogging  of  the  circulation  through  the  gland. 


■"  Pilliet,  Bull,  de  la  Soc.  Anal.,  1892,  p.  137. 
^*  Snow,  Brit.  Med.  /our.,  vol,  i.,  1892,  p.  549. 


l8o  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

When  associated  with  mammary  cancer,  this  glandular 
enlargement  is  usually  followed,  after  a  time,  by  the  develop- 
ment in  the  affected  glands  of  cancerous  growths  precisely 
similar  in  character  and  structure  to  the  primary  neoplasm. 
This  indicates  that  the  secondary  growths  are  derivatives  of 
the  primary  one.  Yet  it  is  exceptional  to  find  any  direct 
continuity  between  the  two.  Wherein,  then,  does  the  connec- 
tion consist  ?  We  have  seen  that  the  lymph  radicles  commu- 
nicate directly  with  the  cancer  alveoli.  Hence,  detached  cellular 
elements  from  the  neoplasm  may  easily  enter  the  lymphatics, 
and  be  carried  by  the  lymph  stream  into  the  adjacent  glands, 
just  as  happens  with  particles  of  colouring  matter  after  tattoo- 
ing. From  the  smallness  of  the  lymph  radicles  it  may  be 
inferred  that  such  transported  fragments  must  be  exceedingly 
minute — probably  a  single  cell  or  a  small  cellular  group  in  most 
cases.  That  epithelial  cells  thus  dis-severed  from  their  normal 
connections  may  still  grow  and  multiply,  we  know  from  the 
familiar  process  of  skin  grafting.  Probably  all  mammary 
cancer  cells  are  capable  of  dissemination  ;  but  all  are  not 
capable  of  growing  when  disseminated.  There  are  good 
grounds  for  believing  that  the  majority  of  these  "  cancer 
emboli"  perish  and  are  absorbed,  owing  to  the  metabolic 
activity  (phagocytosis)  of  the  cells  of  the  glands ;  and  that 
onh'  those  with  sufficient  vitality  to  overcome  this  resistance 
originate  dissemination  tumours.  Hence  the  lymph  glands 
form  a  temporary  barrier  to  the  spread  of  the  disease ; 
and  do  not  themselves  usually  become  affected  until  a  con- 
siderable time  after  its  primary  outbreak. 

Gussenbaucr's''^  histological  researches  confirm  this.  He 
found  traces  of  cancer  cells  disseminated  in  the  glands  of  the 
neck,  secondary  to  primary  disease  of  the  lip,  in  twenty-nine  out 
of  thirty-two  consecutive  cases,  and  doubtful  evidence  of  it  in 
the  other  three.  Yet  clinical  experience  proves  that  when  the 
primary  disease  is  extirpated  without  removal  of  the  adjacent 

5'  Zcitschriflf.  Ilcilk.,  iSSi,  Bd.  ii.,  S.  17. 


LYMPH    GLAND    DISSEMINATION.  l8l 

glands,  in  a  large  proportion  of  cases  the  latter  do  not  originate 
recurrences.  Similarly  of  Kiister's,"  117  breast  cancer  extirpa- 
tions, in  which  the  excised  axillary  glands  were  microscopically 
examined,  in  only  two  instances  were  they  found  perfectly  free 
from  any  signs  of  cancerous  dissemination  ;  and  of  six  cases  of 
the  same  disease,  with  no  enlargement  of  the  axillary  glands 
clinically  appreciable,  Gussenbauer  nevertheless  found  —  on 
histological  examination  after  removal — evidence  of  dissemi- 
nation in  these  glands  in  every  case.  But  we  know  from 
clinical  experience  that  after  extirpation  of  cancerous  breasts, 
without  opening  the  axilla,  recurrences  in  the  axillary  glands 
are  proportionately  much  less  frequent  than  this. 

We  have  thus  arrived  at  the  important  conclusion,  that  the 
outbreak  of  the  disease  in  the  lymphatic  glands  is  due  to  grafts 
from  the  primary  neoplasm,  arrested  there,  which  subsequently 
develop  in  accordance  with  their  inherent  tendencies.  This 
explains  the  great  resemblance  always  noticeable  between  the 
primary  and  secondary  growths,  the  significance  of  which  it  is 
impossible  to  ignore.  Moxon  has  sagely  insisted  upon  this. 
He  says^^:  "The  first  cancer  which  appears  has  a  likeness  to 
the  part  in  which  it  appears,  and  the  secondary  cancers  arising 
from  it  have  the  likeness  of  that  first  cancer ;  and  those  who 
doubt  that  they  came  from  that  first  cancer  must  show  us  why 
they  have  that  likeness.".  In  this  connection,  Waring's  experi- 
ments^'' are  of  interest ;  they  show  that  the  cellular  elements  of 
the  secondary,  as  well  as  of  the  primary  growths,  in  cancer  of 
the  pancreas  and  stomach,  produce  the  same  ferments,  &c.,  as 
the  normal  secretory  cells  of  these  parts. 

On  examination  of  affected  glands  removed  at  an  early 
stage  of  the  disease  it  can  generally  be  made  out,  that  the  new 
growth  consists  of  but  a  few  small,  circumscribed  foci,  situated 
in   the  peri-follicular  lymph  sinuses   of  the  cortex,  or  in  their 


^'-    Verliand,  der  deutsche  Gesellschaft f.  Chir.,  Bd.  xii.,  S.  2S8. 
^^  "Debate  on  Cancer,"  Trans.  Path.  Soaely,  Loud.,  1874. 
'^^  Journal  of  Anatomy.,  Oct.,  1893,  p.  142. 


162  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

immediate  vicinity,  that  is  to  say,  in  the  course  of  the  normal 
afferent  lymph  stream.  In  a  case  of  melanotic  cancer  of  the 
breast  with  secondary  lesions  in  the  axillary  glands,  the  dark 
colour  of  the  cells  enabled  Billroth'^^  to  follow  the  extension  of 
the  dissemination  along  the  lymph  sinuses  ;  and  his  observations 
have  since  been  confirmed  and  amplified  by  Zehnder.^"  The 
latter  describes  the  initial  foci  as  increasing  in  size  by  continuous 
proliferation  of  their  constituent  cells,  which  soon  assume  the 
alveolar  arrangement,  just  as  in  the  development  of  the  primary 
tumour  in  the  breast.  These  cells  are  very  rich  in  karyokinetic 
figures  ;  and  they  can  easily  be  distinguished  from  the  cells 
(lymphoid)  of  the  parenchyma  of  the  gland,  which  show  no  signs 
of  reproductive  activity,  and  appear  not  to  participate  in  the 
spread  of  the  disease.  Petrick^''  has  arrived  at  similar  conclu- 
sions. Finally,  by  multiple  staining,  Gibbes''*^  has  conclusively 
demonstrated  the  correctness  of  this  interpretation.  Large  mul- 
ti-nucleated cells,  the  so-called  "giant  cells  of  cancer,"  are  also  of 
frequent  occurrence.  As  the  cancerous  grafts  increase  in  size, 
the  parenchymatous  cells  of  the  gland  suffer  atrophy  from 
pressure  ;  the  blood-vessels  of  the  stroma  enlarge,  and  their 
endothelial  and  muscular  coats  thicken.  The  endothelial  cells 
of  the  lymph  vessels  and  glands  show  no  visible  alterations,  and 
they  evidently  take  no  active  part  in  the  process.  In  its  subse- 
quent course  the  disease  progresses  precisely  as  the  primary 
outbreak. 

Although  the  lymphatics  connecting  the  cancerous  breast 
with  the  affected  glands  are  usually  free  from  disease,  it  occa- 
sionally happens  (one  in  twenty  according  to  Broca)  that  they 
are  found  distended  with  cancer  cells.  The  so-called  lymph 
cord,  often  to  be  felt  passing  from  the  mammary  tumour  to  the 
axillary  glands,  is  usually  nothing  more  than  the  pedicle  of  the 


"  Arch.  f.  path.  AitaL,  Bd.  21,  S.  441.  1 

■''"  "  Ueber  Krebsentvvicklung  in  Lymphdriisen."   Arch.  f.  path.  A/tat.,  Bd.  cxix. 
Heft  2,  1890,  S.  261. 

■'  Deutsche  Zeitschr./.  Chir.,  1S91,  Bd.  xxxii.,  S.  530. 

*"  International  fournal  of  Medical  Science.,  Auj^ust,  1889,  p.  145. 


LYMPH    GLAND    DISSEMINATION.  1 83 

axillary  tail  of  the  mamma  itself.  The  glands  first  affected  are 
those  that  receive  their  lymph  directly  from  the  part  of  the 
organ  involved  by  the  primary  neoplasm ;  and  the  subsequent 
spread  of  the  disease  from  gland  to  gland  corresponds  to  the 
course  of  the  lymph  stream  ;  but  it  must  be  borne  in  mind  that 
each  infected  gland  constitutes  a  new  centre  of  dissemination. 
In  cancer  we  never  meet  with  any  general  infection  of  the 
lymphatic  system,  such  as  is  often  observed  in  tubercle,  syphilis, 
and  other  infective  diseases.  This  important  fact,  taken  with 
the  foregoing  considerations,  is  an  indication  against  the  fancied 
resemblance,  traced  by  some  pathologists,  between  these  diseases 
and  cancer.  Here  it  may  be  mentioned  that  only  malignant  neo- 
plasms have  the  property  of  reproducing  their  like  by  dissemi- 
nation in  the  adjacent  lymph  glands.  The  few  instances  in 
which  it  is  alleged  that  non-malignant  neoplasms  have  mani- 
fested similar  properties,  are  capable  of  being  otherwise 
explained. 

About  a  dozen  lymphatic  glands  are  normally  to  be  found 
in  the  axilla ;  but  in  cases  of  cancer  this  number  is  often  greatly 
exceeded.  In  a  patient  operated  on  by  Gross^^  fifty  diseased 
glands  were  removed,  which  varied  in  size  from  a  small  shot  to 
a  large  nut.  1  have  seen  several  instances  in  which  the  number 
was  nearly  as  great.  This  condition  is  no  doubt  due  to  morbid 
enlargement  of  the  numerous  small  lymph-glandular  structures 
normally  present  in  the  axillary  fat,  although  ordinarily  in- 
visible to  the  naked  eye.  The  number  of  glands  usually  affected 
is  of  course  much  less  than  this,  but  half-a-dozen  or  more  are 
often  obviously  diseased ;  yet  the  resulting  tumours  seldom 
attain  large  size.  When,  however,  only  a  few  glands  are 
involved,  or  but  a  single  one,  tumours  larger  than  usual  often 
ensue.  Cancerous  axillary  glands  generally  remain  discrete ; 
but  sometimes  they  blend  together,  forming  a  single,  hard 
irregular,  nodular  mass. 

In  most  of  our  standard  text-books  the  axillary  glands  are 

'■'''  Ibid.,  March,  188S,  p.  232. 


184  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

described  as  lying  along  the  inner  side  of  the  axillary  vessels.  I 
need  hardly  remind  any  practical  surgeon  that  it  is  useless  to 
seek  for  enlarged  glands,  secondary  to  disease  of  the  breast,  in 
this  position.  The  axillary  glands  that,  as  a  rule,  first  receive 
the  lymphatics  from  the  breast  are  those  situated  on  the  chest 
wall  at  the  lower  part  of  the  inner  side  of  the  axilla,  under  the 
border  of  the  pectoralis  major  muscle  (^pectoral).  These  are  the 
first  to  be  invaded  in  cases  of  cancer.  It  is  well  to  remember 
that  the  axillary  tail  of  the  mamma  lies  close  by  them,  and 
under  certain  circumstances  it  may  easily  be  mistaken  for  an 
enlarged  gland. 

The  remaining  axillary  glands  are  grouped  as  follows  :  {a) 
Those  along  the  inner  side  of  the  large  vessels,  which  receive 
the  lymphatics  from  the  upper  limb  and  are  in  free  communica- 
tion with  the  foregoing  {brachial),  {b)  Those  of  the  posterior 
part  of  the  axilla,  along  the  course  of  the  subscapular  vessels, 
which  receive  lymphatics  from  the  back  {stib scapular),  ic)  A 
few  small  glands  immediately  below  the  clavicle  {infraclavi- 
cular), between  the  pectoralis  major  and  deltoid  muscles,  which 
receive  branches  from  the  arm  and  shoulder,  and  communicate 
above  with  the  inferior  cervical  and  below  with  the  pectoral 
glands,  {d)  There  can  be  no  doubt— as  pointed  out  by  Hyrtl 
and  ReiffeP — that  some  lymphatics  from  the  mamma  reach  the 
glands  at  the  upper  part  of  the  axilla,  through  Mohrenheim's 
space,  without  entering  the  pectoral  group.  These  pass  between 
the  pectoral  muscles  and  enter  the  axilla  above  the  pectoralis 
minor,  where  they  have  often  been  found  infiltrated  in  cases  of 
mammary  cancer. 

These  various  groups  of  glands  communicate — directly  or 
indirectly — with  one  another,  so  that  all  may  eventually  become 
diseased  from  a  single  morbid  focus.  Their  efferent  vessels 
ascend  with  the  subclavian  vein,  and  having  formed  one  or 
more   trunks  terminate,  on    the  left  side  in  the  thoracic  duct, 


fio  <<  j)g  quelques  points  relatif  aux  recidives  et  avix  generalisations  des  cancers  du 
sein  chez  la  fcmme,"  Tktse  de  Paris,  1890. 


LYMPH    GLAND    DISSEMINATION. 


■85 


and  on  the  right  side  in  the  right  lymphatic  duct  or  subclavian 
vein.  Next  to  the  pectoral  glands,  those  in  the  vicinity  of  the 
large  blood  vessels  and  nerves  are  the  ones  chiefly  affected  in 
cancer  of  the  breast — as  far  upwards  as  the  clavicle,  and  some- 
times even  above  this  level. 

When  these  glands  are  extensively  involved  oedema  of  the 
upper  extremity,  from  pressure  on  the  axillary  vein,  may  ensue ; 
and  at  the  same  time  there  often  is  great  pain  from  compression 
of  the  large  nerve  trunks.      Should  this  condition  pass  on  to 


Fig.  37. — CEdema  of  the  upper  limb,  with  impending  gangrene,  from  compression 
of  the  axillary  vein  by  cancerous  glands  {Billroth). 


gangrene  the  suffering  of  the  patient  will  be  very  great,  for  death 
is  then  approaching  in  one  of  its  most  horrible  forms  (fig.  37). 
It  is  for  the  relief  of  such  cases  that  German  surgeons  have 
resorted  to  amputation  at  the  shoulder-joint,  &c. 

The  lymphatics  of  the  breast  are  extremely  abundant.  No 
other  gland  can  compare  with  the  mamma  in  this  respect. 
Moreover,  its  lymphatics  are  relatively  much  more  numerous 
than  its  blood-vessels,  and  their  intercommunications  are  very 
free.     Inasmuch  as  the  spread  of  cancer  and  other  diseases  is 


1 86 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


effected  mainly  through  their  agency,  accurate  knowledge  of 
their  disposition  is  a  matter  of  great  practical  importance.  They 
chiefly  consist  of  two  sets  :    superficial  ones  derived   from  the 


:i   3 


Fig.  38. — The  Lymphatics  of  the  Breast  {Sappey\ 

(i)  Lymphatic  network  of  the  anterior  surface  of  the  gland.  (2)  Glandular  lobules 
whose  peripheral  network  has  not  been  injected,  so  as  to  allow  the  circumlobular 
lymphatics  to  be  seen.  (3)  Lymphatic  trunks  from  the  superior  and  inferior  segments 
of  the  gland.  (4)  Subareolar  lymphatic  plexus.  (5)  Lymphatic  vessel  arising  from 
inner  part  of  this  plexus,  and  the  proceeding  by  curved  course  towards  the  axilla. 

(6)  Another  vessel  arising  from  outer  part  of  plexus,  and  passing  directly  outwards. 

(7)  Vessel  arising  from  inferior  part  of  the  gland  eventually  uniting  with  preceding. 

(8)  Vessels  arising  from  outer  part  of  sub-areolar  plexus,  and  from  upper  part  of 
gland  proceeding  to  the  axilla. 


skin,  and  deep  ones  from  the  gland.  The  superficial  lymphatics 
are  most  abundant  in  the  nipple  and  areola,  where  they  form  fine 
networks.      From   these  a  variable  number  of  branches   arise 


LYMPH    GLAND    DLSSEMINATION.  1 87 

which  join  the  subareolar  lymphatic  plexus,  towards  which  the 
deep  lymphatics  from  the  gland  itself  also  converge.  The 
lymphatics  of  the  mammary  gland  are  unequally  distributed  on 
its  two  surfaces,  the  anterior  set  being  the  larger  and  more 
numerous.  Most  of  the  large  trunks  that  go  to  the  axilla  arise 
from  these  vessels.  Each  acinus,  lobule  and  lobe,  is  surrounded 
by  intercommunicating  lymphatic  anastomoses.  The  branches 
from  these  various  sources  converge  towards  the  areola  beneath 
which  their  large  trunks  communicate  freely,  forming  the 
subareolar  plexus  of  Sappey.  This  plexus  is  the  meeting  point 
of  the  chief  mammary  lymphatics.  Hence  cancerous  neoplasms 
originating  in  this  part  of  the  gland  are  particularly  apt  to  be 
attended  by  widespread  acute  local  diffusion. 

From  this  plexus  two  main  trunks  arise — one  from  its  outer 
and  one  from  its  inner  side — which  course  in  the  subcutaneous  fat 
to  the  axilla  (fig.  38).  Each  receives  one  or  more  branches  from  the 
upper  and  lower  peripheral  parts  of  the  gland.  Sometimes  these 
peripheral  branches  join  the  axillary  glands  independently.  In 
the  axilla  it  is  rare  to  find  more  than  two  or  three  large  lymphatic 
trunks.  The  above  description  is  mainly  after  Sappey  f^  but  I 
think  this  distinguished  anatomist  is  in  error  in  maintaining  that 
all  the  lymph  from  the  breast  necessarily  passes  through  the 
subareolar  plexus.  There  are  other  lymphatics  proceeding  from 
the  breast,  besides  those  described  by  him.  Some  accompany 
the  bloodvessels  (perivascular).  These  consist  merely  of  a  layer 
of  endothelial  cells,  lining  the  connective  sheaths  of  the  vessels 
they  accompany.  Numerous  other  efferent  branches,  as 
Langhans^^  has  shown,  pass  from  the  posterior  part  of  the  breast 
into  the  loose  retro-mammary  connective  tissue,  whence  they 
proceed  to  the  axilla,  without  ever  entering  the  subareolar  plexus. 
Through  these  branches  cancer  frequently  disseminates.  Some 
lymphatics,  from  the  deep  aspect  of  the  breast,  also  enter  the 


^'  "  Ues  vaisseaux  lymphatiques,"  Paris,  1885,  p.  48  e(  se(2. 

^     "  Die  Lymphgefasse  der  Brustdriise  und  ihre  Beziehungen  zum  Krebse,"  J>r/i. 
f.  Gv'i.,  Bd.  viii.  1873,  S.  184. 


1 88  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

chest  through  the  pectoral  and  intercostal  muscles,  and  so  come 
into  close  relationship  with  the  pleura.*^^  Branches  from  its 
upper  part  sometimes  pass  directly  to  the  subclavicular  and 
inferior  cervical  glands.  Others  from  its  sternal  part  pass 
through  the  second,  third,  fourth,  and  fifth  intercostal  spaces  to 
the  anterior  mediastinal  (retro-sternal)  glands,  where  they  com- 
municate with  the  anterior  intercostal,  internal  and  external 
mammary  branches.  It  is  strange  that  cancerous  dissemination 
does  not  affect  these  glands  more  frequently  than  it  appears  to 
do.  Torok  and  Wittelshofer  found  them  diseased  only  in  6*5 
per  cent,  of  all  their  necropsies.  In  this  connection  it  is  of 
interest  to  recall  the  previously  mentioned  fact,  that  cancer  ori- 
ginates in  the  sternal  segment  of  the  gland,  much  less  frequently 
than  in  any  other  part. 

The  para-mammary  lymphatics  communicate  on  the  one 
hand  with  circumferential  mammary  branches — from  both  tlie 
superficial  and  deep  aspects  of  the  gland — and  on  the  other  with 
the  subcutaneous  thoracic  lymphatics.  Through  these  channels 
the  lymph  systems  of  both  breasts  communicate  indirectly. 
Thus  may  be  explained  those  rare  instances  in  which  cancer  of 
one  breast  has  caused  disease  of  the  glands  in  both  axillae 
(Scarpa,  Cooper,  Moore,  &c.),  and  others  in  which  cancer  of  the 
sternal  segment  of  one  breast  has  induced  secondary  disease  in 
the  glands  of  the  opposite  axilla  (Volkmannj.  In  a  case 
mentioned  by  Moore,^*  cancer  of  the  left  breast  disseminated  not 
only  in  the  glands  of  the  left  axilla  and  groin,  but  also  in  those 
of  the  opposite  breast. 

It  is  a  matter  of  considerable  practical  importance  to  deter- 
mine how  soon  after  detection  of  the  primary  neoplasm  the 
axillary  lymph  glands  become  diseased.     According  to  Fink"^ 


•^  Through  the  medium  of  numerous  arterial,  venous,  and  lymphatic  vessels,  the 
pleur£E  and  mammre  are  closely  related.  Hence  the  frequent  association  of  pleurisy 
and  pleural  effusions,  with  cancerous  and  other  affections  of  the  mamniie  ;  hence  also 
in  certain  intra-thoracic  diseases  the  mammae  may  be  secondarily  involved. 

"*  Med.  Chir.  Trans,,  vol.  xii.,  p.  272. 

"•  Zeitschr.f.  HeilkutiJe,  1888,  Bd.  ix.,  S.  453. 


LYMPH   GLAND    DISSEMINATION.  1 89 

this  happens  as  early  as  from  the  sixth  to  the  twelfth  month  ; 
and  after  the  thirteenth  month  they  are  invariably  invaded. 
Winiwarter  estimated  the  period  at  from  fourteen  to  eighteen 
months.  Gross  gives  the  average  as  177  months.  These  are 
but  clinical  data,  which,  of  course,  do  not  enable  us  to  affirm 
that  the  glands  are  free  from  disease  for  the  whole  period  of 
apparent  immunity.  In  forty-three  of  Kiister's  cases,  with  no 
clinically  appreciable  disease  of  the  glands,  signs  of  cancerous 
dissemination  were,  nevertheless,  found  in  them  on  histological 
examination  after  removal.  In  some  very  rare  instances  gland- 
ular implication  is  so  rapid  that  it  appears  to  coincide  with  or 
even  to  antedate  the  primary  disease.  In  others  it  may  be 
delayed  for  several  years — for  ten  years,  or  even  more,  or  it  may 
never  occur  at  all.  Certain  scirrhous  cancers  may  undoubtedly 
run  their  entire  course,  causing  systemic  dissemination  and 
death,  without  the  adjacent  lymph  glands  ever  being  implicated. 
Hence  the  absence  of  lymph  gland  disease  is  no  absolute 
guarantee  against  general  systemic  dissemination,  which  in  these 
cases  evidently  takes  place  through  the  blood  vessels.  Accord- 
ing to  my  experience,  such  occurrences  are  most  exceptional. 
I  have  met  with  but  a  single  instance  of  the  kind  in  forty-four 
consecutive  necropsies  on  patients  who  had  died  of  mammary 
cancer,  there  being  metastases  in  twenty-eight. 

In  this  case  the  patient  was  a  healthy  looking  woman,  aged  58,  with  a 
hard  cancerous  tumour,  the  size  of  a  hen's  egg,  at  the  upper  part  of  her  left 
breast.  The  nipple  was  normal ;  but  the  overlying  skin  was  adherent  to  the 
tumour,  which  was,  however,  movable  on  the  subjacent  chest  wall.  The 
disease  was  of  three  months  duration.  No  enlarged  glands  could  be 
detected  in  the  axilla  or  elsewhere.  The  diseased  breast  was  extirpated, 
without  interfering  with  the  axilla.  The  patient  made  a  good  recovery  from 
the  operation  ;  but  she  died  five  months  later  of  asthenia,  without  any  sign 
of  recurrence.  At  the  necropsy  the  operation  scar  and  the  adjacent  parts  of 
the  chest  were  found  to  be  healthy  and  quite  free  from  cancerous  disease. 
The  axillary  and  other  adjacent  lymph  glands  were  also  quite  free  from 
disease.  There  were  a  few  firm,  white,  cancerous  nodules,  about  the  size  of 
peas,  on  the  surface  of  each  lung  ;  and  throughout  the  liver  numerous 
cancerous  growths,  varying  in  size  from  a  pea  to  a  hazel  nut. 

According  to  Gross,  metastases  occur  without  any  antecedent 
lymph  gland  dissemination  in  about  one  in  seven  of  all  cases. 


190  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

This  estimate  appears  to  me  too  high,  probably  because  many 
operation  cases  have  been  included.  Torok  and  Wittelshofer's 
figures,  which  are  much  higher  still,  err  also  from  this  cause. 

An  idea  of  the  frequency  of  lymph  gland  dissemination  may 
be  gathered  from  the  following  figures : — 

Of  118  cases  of  primary  cancer  of  the  breast  consecutively 
under  my  observation  there  was  obvious  glandular  disease — 
when  the  patients  were  first  seen — in  86,  or  in  'j'i,  per  cent.  In 
all  of  these  cases  the  axillary  glands  of  the  same  side  as  the 
disease  were  affected  ;  with  the  supra-clavicular  as  well  in  five 
cases,  the  infra-clavicular  in  two,  and  the  glands  of  the  opposite 
axilla  in  two — botJi  breasts  being  involved  in  these  cases.  Gross 
gives  the  proportion  of  cases  of  lymph  gland  dissemination, 
under  like  circumstances,  as  68  per  cent.,  those  of  the  axilla 
being  diseased  in  all,  the  supra-clavicular  in  5-4  per  cent.,  and 
the  infra-clavicular  in  1*3  per  cent. 

Turning  now  to  \}c\.&  post-mortem  evidence,  what  I  have  found 
in  the  cases  under  my  observation  is,  that  of  forty-four  consecu- 
tive necropsies,  there  was  lymph  gland  dissemination  in  forty, 
or  in  90"9  per  cent.  :  the  axillary  glands  were  affected  in  all, 
with  both  the  supra  and  infra-clavicular  ones  in  five  cases,  the 
supra-clavicular  alone  in  two,  the  infra-clavicular  alone  in  four, 
and  those  of  the  opposite  axilla  in  ten  cases  (in  seven  of  these 
both  breasts  were  cancerous).  In  three  of  the  four  cases  in  my 
list  free  from  lymph  gland  disease,  cancerous  axillary  glands 
had  just  previously  been  removed  by  operation. 

From  this  it  follows  that  dissemination  in  the  adjacent 
axillary  glands  is,  sooner  or  later,  an  almost  invariable  con- 
comitant of  acinous  (scirrhous)  cancer  of  the  breast  ;  the  cases 
that  run  their  course  without  it  are  of  the  greatest  rarity. 
Should  anyone  oppose  to  this  conclusion  Torok  and  Wittel- 
shofer's analysis  of  366  necropsies,  in  which  the  axillary  glands 
were  found  invaded  only  in  175  or  48  per  cent.;  my  answer 
is,  that  these  statistics  are  useless  for  determining  the  point 
under  consideration,  because  of  the  large  number  of  operation 
cases  they  include,  in  which  the  affected  lymph  glands  had 
recently  been  removed. 


GENERAL    DISSEMINATION.  I9I 

It  is  commonly  stated  that  the  progress  of  the  disease  is 
much  slower,  and  the  total  duration  of  life  much  longer,  in  cases 
where  lymph  gland  dissemination  is  long  delayed,  than  in  those 
where  the  glands  are  attacked  at  an  early  period  of  the  disease. 
I  am  not  aware  of  any  statistical  evidence  that  can  be  adduced 
in  support  of  this  belief;  but  my  impression  is  that  it  is  well 
founded. 

It  is,  however,  clearly  shown  by  statistics,  that  lymph  gland 
affection  is  an  important  factor  in  determining  the  results 
attained  by  operations  for  the  removal  of  the  disease. 

Thus,  according  to  Winiwarter,  after  amputation  of  the  breast 
for  the  primary  disease,  with  removal  of  affected  axillary  glands, 
the  subsequent  duration  of  life  averaged  13  months,  the  total 
duration  being  29  months ;  whereas  in  cases  where  the  breast 
was  amputated,  without  removal  of  axillary  glands — none  being 
obviously  affected — the  subsequent  duration  of  life  averaged  22 
months,  the  total  duration  being  50  months. 

Gross'  statistics  are  equally  conclusive.  Thus  of  136  cases  of 
extirpation  of  the  breast,  in  93  diseased  glands  were  removed  ; 
the  total  duration  of  life  averaged  39-3  months,  and  local  recur- 
rence ensued  on  the  average  in  1*9  months  ;  whereas  in  43  cases 
free  from  obvious  gland  dissemination,  the  average  duration  of 
life  was  527  months,  and  the  average  period  of  recurrence  was 
8  months.  The  latter,  therefore,  lived  13-4  months  longer  than 
the  former;  and  when  recurrence  followed,  it  appeared  6-i 
months  later. 

The  same  author  has  shown  that  the  proportion  of  cures 
after  operation  is  5-10  per  cent,  greater  when  the  axillary  glands 
are  free  from  disease,  than  it  is  when  they  are  obviously  affected. 

&     VI, General  Dissemination. 

The  appearance  of  cancerous  growths  in  various  parts  of 
the  body,  remote  from  the  primary  disease  and  its  derivatives 
(so-called  metastases),  to  which  allusion  has  already  been  made, 
is  one  of  the  most  striking  features  of  the  disease.     It  is  remark- 


192  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

able  that  the  cancers  of  every  locality  have  their  own  special 
modes  of  dissemination,  and  even  the  various  forms  of  the 
disease  in  particular  organs  manifest  differences  in  this  respect. 

The  female  breast  is  one  of  those  parts  of  the  body  in  which 
the  tendency  to  dissemination  is  very  great.  Growths  of  this 
kind  are  met  with  in  considerably  more  than  one  half  (6 1  per 
cent.)  of  all  fatal  cases  of  breast  cancer. 

•  Of  44  consecutive  necropsies  under  my  observation,  systemic 
dissemination  growths  were  found  in  28,  or  in  6yi  per  cent.  Of 
102  necropsies  tabulated  by  Nunn'^'^  they  were  present  in  74,  or 
in  58-8  per  cent.;  and  of  Torok  and  Wittelshofer's  366  necrop- 
sies they  were  met  with  in  215,  or  in  58  per  cent.  The 
percentage  figures  would  be  much  higher,  but  for  the  fact 
that  in  all  the  foregoing  estimates  a  large  proportion  of  cases, 
fatal  shortly  after  operation,  have  been  included.  Ten  of  the 
44  necropsies  in  my  list  were  of  this  nature.  Of  the  remaining 
34  necropsies,  in  which  death  ensued  in  the  natural  .course  of 
the  disease,  there  were  metastases  in  25,  or  in  73-5  per  cent. 

Statements  vary  as  to  the  precise  date  of  onset  of  general 
dissemination  ;  but  there  is  universal  agreement  that  it  is  not 
until  a  comparatively  late  period  of  the  disease — generally 
some  two  or  three  years  after  the  initial  outbreak,  and  about 
15  months  after  invasion  of  the  lymphatic  glands.  Winiwarter, 
Sprengel,  and  Fink  estimate  it  at  25  months,  Henry  at  30,  and 
Oldekop  at  38  months.  As  a  rule,  the  slower  the  progress  of 
the  primary  disease,  the  later  metastases  appear.  Occasionally 
they  form  during  the  first  few  months  ;  and  at  other  times  not 
until  after  the  lapse  of  several  years — even  10  years  or  more. 
According  to  Gross,  out  of  100  cases  with  metastases,  24  form 
within  the  first  year,  3  in  from  13  to  18  months,  18  in  from  19 
to  24  months,  27  in  from  25  to  36  months,  and  28  after  three 
years.  The  average  duration  of  life  after  the  first  appearance 
of  metastases  is,  according  to  my  estimate,  about  two  years 
Growths  of  this  kind   may  exist  for  a  long  time  in  important 


"  Cancer  of  the  Breast,"  p.  130. 


GENERAL    DISSEMINATION.  193 

organs  such  as  the  liver,  lungs,  brain,  &c.,  without  causing  any 
obvious  functional  disturbance. 

In  the  ensemble  of  their  characters — histological  and  other- 
wise— metastatic  cancers  closely  resemble  the  primary  mam- 
mary neoplasm.  They  differ  from  the  latter,  however,  in  that 
they  are  usually  multiple,  and  spring  up  in  several  different 
localities.  Occasionally  the  number  of  metastases  is  very  small, 
and  in  rare  instances  there  may  be  only  a  single  one.  In  soft, 
vascular  organs  like  the  liver,  these  growths  often  attain  im- 
mense size;'''^  but  in  other  parts  they  are  commonly  of  moderate 
dimensions.  Usually  they  present  as  small,  hard,  nodular 
flattened,  or  discoidal  masses,  which  soon  become  cupped  or 
umbilicated,  owing  to  contraction  of  the  older  parts  of  the 
growths ;  but  they  sometimes  take  the  form  of  diffuse  infiltra- 
tions, especially  in  the  pleura  and  bones. 

The  sequence  of  their  development,  and  the  combinations 
of  organs  invaded  are  difficult  to  explain.  The  deep  parts  of 
the  body  are  much  more  frequently  invaded  than  the  superficial; 
but  the  order  of  eruption  in  most  individual  internal  organs  is 
just  the  converse  of  this. 

I  have  seen  it  stated  by  good  authorities,  that  metastases 
invariably  effect  both  of  paired  organs;  but  I  have  convinced 
myself  by  repeated  observations,  that  it  not  so  :  both  are  usually 
affected,  but  often  only  one. 

Sometimes  these  growths  are  exceedingly  numerous  and 
widely  spread  throughout  the  body,  as  in  Velpeau's''**  remark- 
able case  of  mammary  cancer  in  which  hundreds  of  them  were 
found  distributed  throughout  the  general  connective  tissue, 
lungs,  liver,  bones,  muscles,  heart,  stomach,  duodenum,  small 
intestine,  pancreas,  kidneys,  gall  bladder,  vena  cava,  peritoneum, 
dura  mater,  and  thyroid  gland. 


'^'  A  good  example  of  the  acceleration  of  the  growth  of  cancer  owing  to  increased 
blood  supply.  In  like  manner  the  cock's  spur,  transplanted  to  the  comb,  grows  much 
in  excess  of  its  natural  size. 

**"  "  Traite  des  Maladies  du  Sein,"  &c.,  Paris,  1854. 

13 


194 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


An  excellent  example  of  this  widespread  dissemination  was 
lately  brought  before  the  Edinburgh  Medico-Chirurgical  Society 
by  Bramwell  f^  and  Kautorowicz''  has  reported  a  similar  case. 


'^'^" 


I'iG.  39.— Cancer  OF  Both  Breasts;  Lymphatic  Dissemination;  Wide- 
spread Systemic  Dissemination  {Brannvell). 

The  (lark  patch  on  the  inner  side  of  the  left  breast  represents  the  spot  where  a 
cancerous  nodule  was  excised  for  diagnostic  purposes.  The  dotted  lines  show  the 
size  of  the  liver  and  spleen.  The  photograph  was  taken  with  the  patient  looking  up 
at  the  ceiling  ;  it  shows  the  immobility  of  the  right  eye. 

A  single  woman,  aged  40,  came  under  observation  with  numerous  small 
hard,  cancerous  nodules  in  both  breasts,  and  in  the  adjacent  structures. 
Numbers  of  these  nodules  ran  out  as  jjeaded  chains  under  the  surrounding 
skin,  in  all  directions.     Below  the  nipple  of  the  left  breast  was  a  hard,  cir- 


*"  Eilinhuri^h  Med.  Journal,  July  and  Aug.,  1894. 
*  Ceii.f.  allg.  Path.,  «s:c.,  No.  20,  1893. 


GENERAL    DISSEMINATION. 


195 


cumscribed  tumour  the  size  of  a  walnut.  The  axillary  glands  of  both  sides 
were  enlarged  and  hard.  She  had  diplopia  and  was  blind  in  her  right 
eye.  Her  first  intimation  of  any  mammary  disease  was  the  discovery — 
about  three  years  ago — of  a  hard  tumour,  of  no  great  size,  below  the  nipple 
of  her  left  breast.  This  never  increased,  but  two  and  a  half  years  later, 
without  any  obvious  cause,  numerous  nodules  began  to  develop  in  both 
breasts  and  in  the  adjacent  integument.  These  continuously  increased  until 
she  died  of  asthenia  about  half  a  year  after  their  first  appearance.  The 
progress  of  the  disease  was  marked  by  great  debility  and  emaciation,  and 
shortly  before  death  she  became  unable  to  stand  owing  to  painful  swelling 
at  the  upper  part  of  her  left  femur.  No  family  history  of  cancer  or  tubercle. 
At  the  necropsy  numerous  small  hard  secondary  growths  were  found  in 
both  mammie,  the  adjacent  lymph  glands,  the  subcutaneous  cellular  tissue 
of  the  thorax,  abdomen  and  back,  mesentery,  peritoneum,  liver,  spleen, 
ovaries,  kidneys,  suprarenals,  pancreas,  vagina,  uterus,  sciatic  nerves, 
stomach,  pericardium,  pleurae,  dura  mater,  spinal  meninges,  the  left  femur, 
and  in  the  periosteum  of  the  ribs.  Strange  to  relate,  the  lungs  and  brain 
were  unaffected  ;  and  so  was  the  thyroid  gland.  The  liver  and  spleen 
were  converted  into  large,  fibroid,  cancerous  masses  of  stony  hardness. 
The  histological  characters  of  the  disease  were  those  of  acinous  cancer. 
The  tumour  first  noticed  in  the  left  breast  proved  to  be  an  ordinary  fibro- 
adenoma. The  local  dissemination  seemed  to  have  taken  place  through 
the  lymphatics. 

The  following-  analyses  give  a  good  idea  of  the  relative  fre- 
quency with  which  the  various  parts  are  affected. 

Of  forty-four  consecutive  necropsies,  many  of  them  made  by 

myself,  the  seats  of  metastases  were  : — 

Liver 

Lungs  (B.  5,  L.  2,  R.  i)       

Pleura  (B.  5,  L.  i).. 

Femur  (B.  2,  R.  i,  L.  i)      

Retroperitoneal  glands        ...         

Bronchial  glands 

Humerus  (R.  i,  L.  i)  

Kidneys  (B.  2)  

Supra-renals  (B.  i,  L.  i)     

Pancreas 

Vertebrte  (lower  dorsal  and  upper  lumbar) 

Mesenteric  and  omental  glands    

Gastro-hepatic  omental  glands     

Peritoneum 
Uterus 
Ovary  (L.) 
Tibia  (R.) 
Ribs  (B.) 
Spleen 
Duodenum 


m 

20 

cases 

)> 

8 

)) 

)) 

6 

)) 

)> 

4 

5) 

>) 

3 

)J 

196 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


By  massing  Torok  and  Wittelshofer's  numerous  necropsies 
with  tiiose  of  several  other  European  observers,  Gross  has 
brought  together  423  necropsies  on  persons  dead  of  breast 
cancer,  with  the  result  that  metastases  were  distributed  as 
follows  : — 


Per  cent 

Pleura            

in       50*9 

Lung 

,         49-9 

Liver  

,          48-6 

Bones 

,          20-5 

Brain 

9"4 

Ovary 

8 

Mamma  (of  opposite  side) 

7-S 

Dura  mater  ... 

59 

Kidney 

57 

Retroperitoneal  glands 

5-4 

Uterus           

5-2 

Peritoneum 

47 

Spleen 

47 

Stomach       

47 

Pericardium 

4'4 

Bronchial  glands     ... 

3-5 

Mesenteric  glands  ... 

3'3 

Thyroid  gland 

1-8 

Intestines 

1-8 

Suprarenal 

1-8 

Pancreas       

1-6 

Omentum      

,            1-2 

Heart             

•9 

Venous  system 

■9 

Mediastinal  glands 

■9 

Fallopian  tubes 

•9 

Bladder         

7 

Muscles 

7 

Vagina 

•4 

Spinal  cord  ... 

)               '2 

Gisophagus  

>               "2 

Ureter 

>               "2 

The  above  analyses  show  that  metastases  are  of  much  more 
frequent  occurrence  in  some  parts  of  the  body  than  in  others. 

The  liver,  lungs,  pleurae  and  bones  are  their  seats  of  pre- 
dilection ;  while  they  are  very  rarely  found  in  the  lips,  tongue, 
mouth,  pharynx,  cesophagus,  small  intestine,  skin,  mucous  mem- 


GENERAL    DISSEMINATION.  I97 

brane,  ligaments,  tendons,  prostate,  urethra,  bladder,  pelvis, 
clitoris,  vagina,  lachrymal  gland,  parotid,  and  other  salivary 
glands,  eye,  ear,  nose,  thyroid,  vermiform  appendix,  spinal  cord, 
heart,  muscles,  stomach,  uterus,  mamma,  &c.  The  only  parts 
really  quite  exempt  are  avascular  structures  like  cartilage, 
cornea,  &c. 

Careful  examination  of  the  facts  show,  that,  strictly  speaking 
the  mutual  local  exclusiveness  between  primary  and  secondary 
cancers,  announced  by  Virchow,^°  does  not  exist  ;  nevertheless 
it  is  undoubtedly  true,  that  parts  specially  prone  to  originate 
the  disease,  i.e.,  tongue,  lip,  skin,  mouth,  oesophagus,  uterus, 
breast,  stomach,  8z:c.,  are  seldom  the  seats  of  secondary  outbreaks. 

Most  pathologists  are  agreed,  contrary  to  what  is  shown  in 
Gross'  table,  that  the  liver  is  the  organ  most  frequently  affected 
with  metastases  in  mammary  cancer.  My  analysis  of  forty-four 
necropsies  shows  this  in  a  striking  manner;  but  it  would  have 
been  otherwise  had  I  not  carefully  separated  the  true  pulmonary 
metastases  from  those  cases  (twelve  in  all),  in  which  the  lungs 
were  invaded  by  direct  extension  of  the  primary  disease,  or  by  its 
local  dissemination.  The  discrepancy  between  Gross'  analysis 
and  mine  is  evidently  due  to  this  cause.  The  same  criticism 
applies  also  to  "Cc^o.  pleura. 

The  ribs,  sternum,  and  occasionally  the  clavicle,  as  I  have 
previously  mentioned,  not  unfrequently  become  cancerous 
through  direct  extension  of  the  primary  disease  or  through  its 
local  dissemination. 

In  addition  to  this,  however,  as  shown  by  the  subjoined 
analyses,  certain  bones  are  very  prone  to  metastases.     Thus — 


Of 

Torok  and  Witt 

etshofcr's  336  P.M.'s 

Cranial  bones  were  invaded     .. 

in 

33 

cases 

Vertebrae 

,, 

9 

11 

Innominate 

...         ,, 

9 

5) 

Humerus  .. 

,, 

5 

J> 

Femur 

» 

3 

» 

""  "  Path,  des  Tumeurs,"  1867,  t.  i.,  p.  67. 


198 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


Of  Nunn's  123  P.Mh 

Cranial  bones 

were  invaded     ... 

in 

3 

cases 

Ribs 

... 

3 

11 

Vertebrse 

I 

case 

Femur 

I 

., 

Humerus  ... 

I 

>> 

Not  stated 

Of  the  Authot^s  44  P.M.'s 

I 

» 

Femur  was  invaded        

m 

4 

cases 

Humerus  ... 

... 

)» 

2 

7> 

Vertebras 

)j 

I 

case 

Ribs 

... 

»' 

I 

11 

Tibia 

)) 

I 

5) 

By  massing  the  above  we  get  533  necropsies  with  metastases 
in  the  cranial  bones  in  thirty-six,  vertebrae  in  eleven,  innominate 
in  nine,  femur  in  eight,  humerus  in  eight,  ribs  in  four,  tibia  in 
one,  and  not  stated  one. 

The  exalted  position  of  the  cranial  bones  in  this  list  is 
entirely  due  to  Torok  and  Wittelshofer's  analysis,  in  which 
these  bones  were  cancerous  in  9  per  cent,  of  all  necropsies ; 
whereas  in  the  other  two  estimates  they  were  affected  only  in 
r8  per  cent.  In  the  latter  series,  however,  the  cranium  was 
only  opened  when  signs  of  its  disease  had  been  noticed  during 
life,  whereas  in  the  former  the  cranium  was  opened  as  a  matter 
of  routine  in  nearly  every  case.  The  apparent  discrepancy  may 
be  accounted  for  by  the  fact  that  most  metastases  in  the  cranial 
bones  start  in  the  diploe,  and  progress  more  rapidly  inwards 
than  outwards,  owing  to  the  greater  thickness  and  density  of 
the  outer  table.  Probably  also  in  many  of  Torok  and  Whittel- 
shofer's  cases  the  cranial  bones  were  affected  from  within.  It 
accords  with  this  that  they  met  with  intra-cranial  metastases  in 
forty  cases  (iO"9  per  cent.)  ;  whereas  in  the  other  series 
metastases  were  found  here  only  in  seven  cases  (4*2  per  cent.). 
It  may  be  inferred  from  the  above  that  intra-cranial  metastases 
frequently  exist  without  giving  rise  to  any  obvious  symptoms. 
The  scats  of  the  tumours  in  Torok  and  Wittelshofer's  forty  intra- 
cranial cases  were  : — Dura  mater  in  twenty-five,  cerebrum  in 
twenty-two,  cerebellum  in  thirteen,  pia  mater  in  three,  and  pineal 
body  in  two. 


GENERAL    DISSEMINATION.  199 

Metastases  in  the  vertebrcs^'^  almost  invariably  originate  in  the 
bodies ;  usually  several  adjacent  bones  are  affected,  and  in  most 
cases  the  disease  is  situated  in  the  lower  dorsal  or  upper  lumbar 
regions.  As  the  growths  progress  they  often  cause  excruciating 
pain,  and  eventually  kyphosis  or  even  angular  curvature,  and 
sometimes  paraplegia. 

The  following  instance  of  this  kind  came  under  my  observa- 
tion : — 

A  woman,  aged  43,  first  noticed  a  hard  lump — about  the  size  of  a  marble 
— in  her  left  breast  four  years  ago.  As  the  disease  increased  the  breast  was 
amputated,  rather  less  than  two  years  ago.  One  year  later  recurrent  nodules 
were  excised  from  the  same  region.  Since  this  time  she  has  suffered  from 
excruciating  pain  in  the  right  lower  limb — like  sciatica  ;  also  from  abdominal 
pain,  chiefly  in  the  hepatic  region.  A  few  months  after  the  last  operation  a 
fresh  outbreak  of  the  disease  was  noticed  in  the  vicinity  of  the  old  scar. 
When  I  first  saw  her — some  months  later — she  had  several  hard,  cancerous 
nodules  in  this  situation  ;  and  she  was  suffering  much  from  sciatica.  The 
axillary  glands  (left)  were  enlarged  and  hard.  She  died  about  sixteen 
months  later,  and  three  weeks  before  death  paraplegia  supervened.  Nearly 
the  whole  of  this  time  she  was  bed-ridden,  and  suffered  much  pain  in  the 
right  lower  limb,  and  subsequently  in  the  lower  part  of  the  back.  At  the 
necropsy  the  body  was  greatly  emaciated.  There  was  a  hard,  nodulated, 
adherent  mass  of  scirrhous  cancer,  the  size  of  an  orange,  in  the  scar  of  the 
left  mammary  region.  The  axillary  glands  of  this  side  were  enlarged  and 
cancerous.  The  bodies  of  the  lower  dorsal  and  upper  lumbar  vertebrae 
were  soft  and  infiltrated  with  cancerous  growth.  Opposite  the  bodies  of  the 
sixth  and  eighth  dorsal  vertebrse  projections  from  this  growth  compressed 
the  spinal  cord — which  was  here  narrowed  and  diffluent — but  neither  the 
cord  nor  its  membranes  were  infiltrated.  The  upper  part  of  the  left  pleura 
contained  several  small  cancerous  nodules,  probably  the  result  of  local 
dissemination.  In  the  upper  part  of  each  lung  were  old  tubercular  lesions, 
together  with  pleural  adhesions.  Recent  miliary  tubercles  were  scattered 
throughout  the  right  lower  lobe.     There  were  no  other  noteworthy  lesions. 

As  an  example  of  metastases  in  the  innominate  and  pelvic 
bones,  I  will  cite  the  two  following  remarkable  cases  : — 

The  patient,  aged  60,  under  the  care  of  Arnott,"  died  with  ulcerated 
scirrhus  of  the  breast,  of  eight  and  a  half  years  duration,  for  which  no 
operation  had  ever  been  done.  During  the  last  two  years  of  her  life  she 
complained  much  of  pains  in  the  back,  pelvis,  and  thighs.     Three  months 

'•  For  further  details  vide'Deloxme.     "  Etude  sur  le  cancer  de  la  colonne  vertebrale 
consecutif  au  cancer  du  sein,"    These  de  Pa?-is,  1876. 
'-   Trans.  Path.  Socy.,  Lond,,  vol.  xix.,  p.  356. 


200  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

before  death,  complete  paraplegia  supervened,  which  had  been  preceded 
first  by  numbness  of  the  left  lower  limb  (with  the  formation  of  a  slough  over 
the  metatarsus),  and  subsequently  by  hyperaesthesia.  At  the  necropsy  the 
glands  of  both  axillse  and  inguinal  regions  were  found  infiltrated  with  cancer, 
but  there  were  no  deposits  in  any  of  the  viscera.  The  bodies  of  the  four 
lower  lumbar  vertebrae  were  infiltrated  with  cancer,  much  flattened,  and  so 
soft  that  they  could  easily  be  cut  with  a  knife  ;  their  spinous  and  transverse 
processes  were  similarly  affected.  A  globular  cancerous  tumour,  four  inches 
in  diameter,  occupied  the  posterior  part  of  the  left  innominate  bone  above  the 
sciatic  notch,  and  the  adjacent  part  of  the  sacrum  was  extensively  invaded  by 
it.  Projecting  into  the  pelvis  from  the  right  innominate  bone,  over  the  region 
by  the  acetabulum,  was  a  tumour  the  size  of  half  an  orange,  at  the  base  of 
which  the  cancerous  disease  extended  through  the  entire  thickness  of  the 
bone,  and  projected  from  its  external  surface — below  and  behind  the  aceta- 
bulum—as  a  pear-shaped  mass.  The  ischial  tuberosity  was  thickened  and 
infiltrated.  Numerous  small  cancerous  nodules  were  found  throughout 
other  parts  of  both  innominate  bones  and  the  sacrum  ;  and  these  bones 
were  in  places  quite  soft.  The  head  of  the  right  femur,  though  not  changed 
in  form,  was  infiltrated  with  cancer  and  quite  soft. 

The  case  of  an  old  woman,  related  by  Cruveilhier,''^  who  some  time  pre- 
viously had  undergone  amputation  of  the  breast  for  cancer,  which  had  not 
returned,  is  very  siniilar  to  the  above.  She  was  seized  with  sev^ere  pains  in 
the  pelvis,  and  inability  to  stand  ;  but  there  was  no  obvious  deformity.  She 
subsequently  died  of  exhaustion  ;  and  on  examination  after  death  it  was 
found  that  the  whole  of  both  innominate  bones  were  carnified  by  diffuse 
cancerous  infiltration,  but  the  periosteum  was  uninvaded. 

When  cancer  disseminates  in  the  bones,  several  are  usually 
involved,  but  quite  exceptionally  only  one.  Moreover  it  is  rare 
for  disseminative  lesions  to  be  limited  solely  to  the  osseous 
system,  as  in  the  above  cases,  and  the  following  ones  by 
Walther,"''  &c. 

A  woman,  aged  60,  died  with  ulcerated  scirrhous  cancer  of  the  lower  and 
outer  part  of  the  left  breast,  and  numerous  small,  hard  nodules  disseminated 
in  its  vicinity,  no  deep  infiltration  of  the  subjacent  parts.  On  post-mortem 
examination,  secondary  growths  were  found  in  the  cranial  bones,  the  upper 
part  of  the  left  femur,  and  in  the  bodies  of  the  sixth  and  seventh  dorsal  ver- 
tebrae, but  none  elsewhere. 

In  a  case  of  which  there  is  a  plaster  cast  in  St.  Thomas'  Hospital 
Museum  (fig.  40),  the  secondary  deposits  in  the  bones  were  diffuse.  The 
patient  died  after  amputation  of  her  right  breast  for  cancer.  The  scar  in  the 
mammary  region  appeared  quite  healthy;  and  the  only  obvious  lesions  were 
confined  to  the  osseous  system.     At  the  necropsy  the  skeleton  was  greatly 


"  Anat.  Path.,  liv.  20,  p.  2. 

'*  Bull,  de  la  Soc.  Anat.,  1890,  p.  423. 


GENERAL    DISSEMINATION. 


20I 


distorted.  The  thorax  had  flattened  transversely  ;  the  sternum  and  ribs 
having  sunk  in,  so  that  the  former  ahnost  touched  the  spinal  column.  The 
pelvis  exhibited  somewhat  similar  deformity.  The  right  humerus  and  both 
femora  had  undergone  spontaneous  fractures  at  their  upper  parts  ;  and  the 
fragments  had  united  in  very  faulty  positions.  There  was  diffuse  cancerous 
infiltration  of  the  medulla  of  the  fractured  bones  ;  and  on  microscopical 
examination,  the  new  growth  was  found  to  consist  of  alveolar  cancer,  very 
like  the  ordinary  scirrhus  of  the  breast. 


Fig.  40. — Multiple  spontaneous  fractures  from  dissemination  in  the  bones  {Sno-v). 


Of  the  long  bones  metastases  are  commonest  in  the  femur  ^.xxd 
humerus  ;  both  sides  are  generally  affected,  but  often  only  one. 

As  an  instance  of  wide-spread  dissemination  of  this  kind, 
mention  may  be  made  of  a  case  I  once  saw,  in  which,  several 
years  after  amputation  of  the  left  breast  for  primary  cancer, 
recurrence  took  place  in  the  mammary  region  ;  and  metastases 
subsequently  formed  in  the  liver,  spleen,  retro-peritoneal  glands  ; 
as  well  as  in  the  following  bones  (all  of  which  fractured  spon- 
taneously)— both  humeri,  right  clavicle,  third,  fourth,  and  fifth 
right  metacarpals,  and  the  left  femur.  In  this  case  the  osseous 
growths  were  cumcumscribed. 


202  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

In  the  femur  metastases  generally  originate  in  the  medulla 
at  about  the  middle  of  its  upper  half;  and  in  the  humerus  at  the 
junction  of  its  upper  and  middle  thirds.  As  the  growths  in- 
crease, they  cause  "  pressure  atrophy "  of  the  cortex,  and  so 
eventually  spontaneous  fractures.  Until  this  happens,  osseous 
metastases  seldom  give  rise  to  symptoms — other  than  quasi- 
rheumatic  pains.  In  making  post-mortem  examinations  I  have 
several  times  found  secondary  growths  in  these  bones,  whose 
presence  had  never  been  so  much  as  suspected  during  life. 

I  have  often  noticed  around  growing  endosteal  cancers,  a 
more  or  less  extensive  zone  of  decalcified  osseous  tissue ;  this 
preparatory  softening  of  the  adjacent  bone  no  doubt  accounts 
for  the  ease  and  rapidity  with  which  the  growths  progress, 
notwithstanding  the  apparently  unyielding  nature  of  their  sur- 
roundings. Fractures  due  to  metastases  generally  excite  a  great 
deal  of  swelling,  and  they  are  usually  followed  by  free  formation 
of  callus,  so  that  firm  union  is  sometimes  attained. 

There  can  be  no  doubt  that  dissemination  in  the  osseous 
system  occurs  very  much  more  frequently  in  connection  with 
cancer  of  the  breast,  than  with  cancer  of  any  other  part  of  the 
body.  I  have,  however,  met  with  metastases  in  the  right  tibia, 
secondary  to  cancer  of  the  cervix  uteri ;  and  in  the  seventh  and 
eighth  dorsal  vertebrae  (causing  paraplegia),  secondary  to  cancer 
of  the  lower  part  of  the  rectum :  moreover,  I  know  of  several 
other  similar  cases.^* 

Of  these,  the  University  College  case  presents  so  many 
remarkable  features  that  I  subjoin  a  brief  account  of  it : — 


"  Q.  V.  Barth  Hasp.  Rep.,  1888,  p.  389.  "  Cancer  of  cervix  uteri  with  dissemi- 
nation in  the  X^h  femur." 

Univ.  Coll.  flosp.  Rep.,  1888,  p.  92  and  ji.  142.  "  Cancer  of  ((jrz'/a- w/^;-/ with 
dissemination  in  upper  part  of  right  humerus. 

Middlesex  IIosp.  Museum  Catalogue,  p.  69,  No.  600.  "  Cancer  of  c^y-w/.r  «/(?;-/ 
with  dissemination  in  the  ribs." 

Trans.  Path.  Soc,  Lond.,  1891.  "  Cylinder-celled  epithelioma  of  r(r/?<w  with 
dissemination  in  right  humerus." 

Cruveilhier's  Anat.  Path.,  liv.  20,  p.  5.  "  Cancer  n^  stomach  with  dissemination 
in  right  humerus." 


GENERAL    DISSEMINATION.  203 

The  patient,  aged  52,  came  to  the  hospital  on  account  of  painful  swelling 
at  the  upper  part  of  her  right  arm,  of  two  months  duration.  She  complained 
also  of  considerable  loss  of  power  in  the  part,  which  began  to  weaken  about 
a  year  ago.  On  examination  there  was  found  great  enlargement  of  the  upper 
end  of  the  humerus,  which  extended  as  far  down  as  the  insertion  of  the 
deltoid.  The  overlying  skin  was  reddened,  and  the  subcutaneous  veins  were 
much  enlarged.  There  was  great  loss  of  power  in  the  limb,  and  constant 
"gnawing"  pain  was  experienced,  which  extended  down  to  the  elbow. 
Passive  movements  at  the  shoulder  joint  could  be  effected,  but  they  caused 
much  pain.  There  was  family  history  of  phthisis  ;  and  a  sister  had  died  of 
internal  cancer.  Her  previous  health  had  never  been  good.  The  swelling 
was  aspirated,  but  only  some  blood  and  fatty  matter  came  away.  Under 
these  circumstances  it  was  resolved  to  amputate  at  the  shoulder  joint. 
During  manipulation,  prior  to  operation,  the  bone  fractured  through  the 
surgical  neck.  The  part  was  removed  by  cutting  the  deltoid  flap  by  dissec- 
tion, and  the  internal  flap  by  transfixion,  with  antiseptic  precautions.  The 
upper  part  of  the  humerus,  as  far  down  as  the  insertion  of  the  deltoid,  was 
found  to  be  involved  by  a  cancerous  growth  ;  but  the  cartilage  of  the  head 
was  intact.  The  wound  healed  quickly  ;  but  the  patient's  health,  neverthe- 
less, progressively  deteriorated,  and  she  died  about  seven  months  after  the 
peration.  Some  time  prior  to  this  it  was  discovered  that  she  was 
suffering  from  ulcerated  cancer  of  the  cervix  uteri,  to  which  the  cancerous 
tumour  of  the  humerus  was  tv\6.t\it\y  secondary.  Histologically  examined, 
the  latter  growth  consisted  of  fibrous  stroma  containing  numerous  small 
spaces,  for  the  most  part  lined  by  but  a  single  layer  of  short  columnar  cells, 
but  some  of  the  spaces  were  filled  with  cells  of  a  more  flattened  type.  The 
appearances  were  similar  to  those  met  with  in  cancer  of  the  cervix-  uteri. 

I  have  seen  several  instances  in  which  elderly  women  with 
mammary  cancer  have  sustained — in  consequence  of  some 
trivial  accident — spontaneous  fracture  of  the  upper  part  of  the 
femur.  Usually  such  cases  have  been  mistaken  for  ordinary 
senile  intra-capsular  fracture  ;  until,  after  a  time,  the  presence 
of  mammary  cancer  has  been  discovered.  Spontaneous  fractures 
of  the  upper  part  of  tlte  femur  in  emaciated,  sallow,  elderly  women 
should  always  be  regarded  as  suspicious  of  mammary  cancer. 
The  two  following  cases  illustrate  this  : — 

(i)  A  pale,  sallow  and  emaciated  woman,  aged  49,  came  under  treat- 
ment on  account  of  having  recently  fractured  her  left  femur  when  turning  in 
bed.  On  examination  there  was  found  great  swelling  at  the  upper  third  of 
the  thigh,  and  the  bone  was  obviously  fractured  at  this  situation.  Some  time 
afterwards  there  was  accidentally  discovered  a  nodular  tumour  of  extreme 
hardness,  the  size  of  a  bantam's  Qg'g,  in  the  upper  and  axillary  segment  of 
her  right  breast.  The  nipple  was  retracted,  and  the  overlying  skin  adherent  ; 
but  the  tumour  was  movable  over  the  subjacent  parts.     At  the  junction  of 


204  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

the  first  and  second  pieces  of  the  sternum,  there  was  a  hard  flattened  swell- 
ing as  from  a  cancerous  growth.  The  axillary  glands  were  enlarged  and 
hard.  When  questioned,  the  patient  said  she  first  noticed  a  lump  in  her 
right  breast  three  months  before  breaking  her  femur.  She  had  suffered 
much  from  rheumatic  pains  for  a  year,  and  on  this  account  she  had  been 
confined  to  her  bed  for  four  months.  She  died  of  asthenia  about  three 
months  later,  when,  in  addition  to  cancerous  growths  in  the  femur  and 
sternum,  both  pleurae,  the  liver,  and  the  axillary  glands  contained  secondary 
growths,  all  of  them,  like  the  primary  disease,  of  the  atrophic  type. 

(2)  This  patient,  aged  60,  also  came  under  treatment  on  account  of 
having  recently  sustained  a  spontaneous  fracture  of  the  upper  extremity  of 
her  right  femur,  at  the  junction  of  the  shaft  and  great  trochanter.  She  was 
emaciated  and  sallow.  It  was  subsequently  discovered  that  she  had  in  the 
central  part  of  each  breast  a  hard  nodular  cancerous  tumour,  the  size  of  half 
a  small  orange.  The  overlying  skin  on  both  sides  was  adherent,  and  over 
the  right  tumour  the  skin  was  eroded.  The  adhesions  with  the  subjacent 
parts  were  but  slight.  Both  tumours  were  exceedingly  hard.  A  tumour  in 
the  right  breast  was  first  noticed  one  year  ago.  The  axillary  and  infra-cla- 
vicular glands  of  both  sides  were  enlarged  and  hard.  She  died  of  asthenia 
about  a  month  later.  At  the  necropsy  there  was  found  to  be  a  fracture  of 
the  right  femur  in  the  position  above  indicated.  At  this  spot  there  was  a 
large  mass  of  whitish  cancerous  growth  with  calcareous  deposit  in  it.  The 
medulla  of  the  upper  part  of  the  shaft  was  infiltrated  and  the  cortex 
atrophied.  The  adjacent  soft  parts  and  the  glands  of  the  groin  were 
invaded.  On  sawing  open  the  left  femur,  which  presented  externally  no 
obvious  sign  of  disease,  I  found  a  cancerous  growth  the  size  of  a  walnut,  in 
the  medulla,  at  the  junction  of  the  shaft  with  the  great  trochanter.  Here  the 
cortex  of  the  bone  had  been  eaten  away  by  contact  with  the  cancerous 
nodule,  and  it  was  almost  perforated.  There  were  secondary  cancerous 
growths  in  the  third,  fourth,  and  fifth  ribs  of  the  right  side  on  the  antero- 
lateral aspect  of  the  chest ;  and  a  similar  growth  in  the  fifth  left  rib.  In 
these  positions  the  bones  were  fractured.  The  liver,  mesenteric  and  omental 
glands,  with  the  pleurae,  as  well  as  the  glands  of  both  axillary  and  infra- 
clavicular regions,  were  also  the  seats  of  secondary  growths. 


On  a  prioTi  grounds  there  seems  to  be  no  reason  why  cancer 
of  one  breast  should  not  cause,  by  systemic  dissemination, 
secondary  disease  in  the  opposite  breast,  and  of  this  condition 
the  last  recorded  case  seems  to  be  an  example.  Metastases  in 
the  breast,  secondary  to  cancer  elsewhere  than  in  the  mamma, 
are  by  no  means  unknown.  I  have  seen  instances  of  this  kind 
in  which  the  primary  disease  was  in  the  uterus,  ovary,  rectum 
and  peritoneum.  Of  the  first  of  these  I  will  give  a  brief 
abstract. 


GENERAL    DISSEMINATION.  205 

The  patient  was  a  married  woman,  aged  49,  the  mother  of  one  child. 
One  and  three-quarter  years  ago,  she  first  became  subject  to  sanious  vaginal 
discharge,  and  shortly  afterwards  flooding  set  in.  She  had  since  been  subject 
to  return  of  the  latter  condition  every  two  or  three  months.  Eight  months 
ago  the  cancerous  cervix  was  amputated.  She  was  relieved  for  two  months, 
when  the  old  symptoms  returned.  Four  months  ago  she  first  noticed  a  lump 
in  her  left  breast,  the  size  of  a  hazel  nut ;  and  two  months  later  a  small 
nodule  in  the  skin  over  the  upper  part  of  the  sternum.  When  first  seen  by 
me  she  had  profuse  sanio-puriform  vaginal  discharge  ;  and  the  portio 
vaginalis  uteri  was  replaced  by  a  hard,  nodular,  ulcerated  surface,  with 
infiltration  of  the  adjacent  parts  of  the  bladder,  vagina  and  rectum.  She 
complained  of  pain  in  the  sacral  and  genital  regions,  and  of  difficult  and 
painful  defcccation.  At  the  lower  and  axillary  part  of  her  left  breast  was  a 
hard,  flattened  nodule,  the  size  of  half  a  walnut,  adherent  to  the  overlying 
skin,  but  movable  on  the  subjacent  parts  ;  the  nipple  normal  ;  and  the 
axillary  glands  not  obviously  affected.  In  the  skin  over  the  left  edge  of 
the  sternum,  level  with  the  second  costal  cartilage,  was  a  hard  nodule  the  size 
of  a  pea.  She  died  of  asthenia  six  months  later  ;  and  there  was  no  necropsy. 

The  massed  statistics  of  Gross  show  dissemination  in  the 
uterus  in  5 '2  per  cent,  of  all  breast  cancer  necropsies.  In 
Nunn's  123  necropsies  it  was  met  with  in  four;  and  in  my 
forty-four  necropsies  in  one ;  or  in  about  3  per  cent,  of  these 
167  necropsies.  Uterine  metastases  almost  invariably  affect 
the  body  of  the  organ,  generally  its  peritoneal  surface.  In  a 
case  under  my  observation  several  nodules  were  found  in  this 
situation,  as  well  as  in  both  pleurae,  the  right  femur,  and  the 
right  humerus.  In  very  exceptional  cases,  however,  we  do  find 
dissemination  in  the  cervix  uteri  secondary  to  mammary  cancer  ; 
under  these  circumstances  the  uterine  lesion  debuts  as  a  nodule^'^ 

Bryant"  has  put  on  record  a  case  of  this  kind.  His  patient,  aged  50, 
came  under  observation  with  infiltrating  cancer  of  the  breast,  of  two  years 
duration.  The  axillary  glands  were  not  affected.  The  breast  was  ampu- 
tated without  interfering  with  the  axilla.  Four  years  later,  being  quite  free 
from  any  return  of  the  cancerous  disease,  melanotic  sarcoma  developed  in  a 
mole  of  the  skin  of  the  left  armpit.  In  the  course  of  six  months  it  increased 
to  the  size  of  a  hazel  nut.  It  was  then  excised,  and  there  was  no  return  of 
this  disease.  Eight  years  after  amputation  of  the  breast  the  left  arm  became 
oedematous  and  swollen,  and  a  painful  swelling  developed  at  the  upper  part 
of  the  left  femur.    About  the  same  time  she  had  "  flooding,"  and  a  cancerous 

'"  For  instances  of  the  independent  outbreak  of  cancer  in  the  breast  and  uterus 
vide,  eh.  x.,  §  9. 

''  "  Diseases  of  the  Breast,"  p.  340. 


206  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

nodule — the  size  of  a  hazel  nut — was  found  in  the  cervix  uteri.  Six  months 
later  recurrent  cancerous  nodules  were  for  the  first  time  noticed  in  the  left 
mammary  region  in  the  vicinity  of  the  old  operation  scar  ;  and  when  turning 
in  bed  she  fractured  her  left  femur  at  the  seat  of  the  painful  swelling.  She 
died  a  few  months  later — nine  years  after  extirpation  of  the  primary  disease. 
There  was  no  necropsy.  Here,  I  think,  we  evidently  have  a  case  of  recur- 
rence in  the  mammary  region — at  first  unnoticed — followed  by  dissemina- 
tion in  the  cervix  uteri.,  femur,  &c. 

Brodie'*  mentions  an  instance  of  cancer  en  cuirasse  of  the  female  breast, 
with  metastases  in  the  liver  and  cervix  uteri. 

In  Nunn's'-'  case  of  associated  cancer  of  the  cervix  uteri,  both  breasts 
and  liver,  the  disease  probably  originated  in  the  uterus,  and  disseminated  in 
the  other  organs. 

Gross'  statistics  show  metastases  in  the  ovaries  in  8  per  cent, 
of  all  breast  cancer  necropsies.  Of  Nunn's  and  my  1 67  necropsies, 
ovarian  dissemination  was  met  with  in  eight  cases,  or  in  4'8  per 
cent.  In  four  of  these  cases  both  ovaries  were  affected,  and  in 
four  only  one.  Coupland*^*^  has  met  with  a  case  in  which  both 
breasts  aiid  ovaries  were  cancerous. 

The  patient  was  a  stout,  healthy-looking  Irish  brunette,  only  24  years  old, 
who  came  under  observation  with  a  very  hard  subglobular  tumour — about 
three  inches  in  diameter — in  the  sternal  segment  of  her  right  breast,  and  a 
second  small  nodule  in  its  upper  part,  as  well  as  an  enlarged  gland  in  the 
axilla.  The  whole  breast  was  extirpated,  and  the  axilla  cleared.  Five 
months  later  two  small  recurrent  nodules  were  excised  from  the  mammary 
region.  Two  months  afterwards  there  was  sudden  and  rapid  eruption  of 
recurrent  nodules,  beginning  in  the  right  mammary  region  and  spreading  to 
the  left ;  and  soon  afterwards  the  whole  of  the  upper  part  of  the  front  of  the 
chest  on  both  sides  was  invaded  by  cuirassed  cancer,  together  with  the 
glands  of  both  axilla;  and  those  at  the  root  of  the  neck.  As  the  disease 
progressed,  cyanosis  supervened,  with  dyspnoea  and  asphyxia,  of  which  she 
died  a  fortnight  after  the  onset  of  the  acute  cancerous  outbreak.  At  the 
necropsy,  in  addition  to  the  above  mentioned  lesions,  the  surface  of  the 
heart  was  the  seat  of  diffuse  cancerous  dissemination,  as  well  as  both 
ovaries.  Histologically,  the  breast  cancer  was  of  the  ordinary  acinous  type, 
and  that  of  the  ovaries  is  described  as  medullary.  There  was  effusion  of 
fluid  into  the  left  pleura  ;  the  other  organs  were  normal. 

This  case  has  lately  been  cited  as  an  example  of  primary 
multiplicity,  as  it  appears  to  me,  without  adequate  reason,  for 


"  Lectures  on  Path,  and  Surgery,"  1846,  p.  209. 

"  Cancer  of  the  P.reast,"  p.  106. 

Trans.  I'alh.  Soi.,  Loud.,  vol.   xxvii.,  p,  26. 


GENERAL    DISSEMINATION.  20/ 

had  the  ovarian  outbreaks  been  of  independent  origin,  the  pelvic 
lymph  glands,  &c.,  would  have  been  invaded. 

By  far  the  most  feasible  explanation  known  to  me  of 
the  phenomena  of  systemic  dissemination  is  that  furnished  by 
the  "embolic  theory."  This  implies  that  the  germs  whence 
metastases  arise  are  proliferous  cells,  detached  from  the  primary 
neoplasm  or  its  derivatives,  and  carried  off  by  the  blood  stream. 
These,  by  their  continuous  proliferation,  directly  originate  the 
secondary  growths ;  so  that  the  first  cancer  is  the  parent  of  all 
that  form  after  it.  The  conception  of  metastases,  as  due  to 
specific  virus  (blastema,  &c.)  dissolved  in  the  blood,  belongs  to 
old  humoral  pathology,  and  now  finds  no  support,®^  except 
with  those  who  would  revive  the  old  doctrine  in  connection  with 
the  microbe  theory.  It  has  been  proved  by  many  observers 
that  cancer  cells  enter  the  blood  stream  directly  through  the 
blood  vessels — especially  the  small  veins — as  well  as  indirectly 
through  the  lymphatics.  In  the  latter  instance,  cancer  cells 
taken  up  by  the  mammary  lymphatics,  and  not  arrested  by  the 
glands,  are  carried  on  with  the  lymph  stream  into  the  large 
veins  at  the  root  of  the  neck.  Astley  Cooper,  Andral  and 
others  have  found  free  "  cancer  emboli "  in  the  thoracic  duct 
and  in  the  large  lymphatic  trunks  of  this  locality;  and  these 
vessels  have  often  been  found  plugged  with  cancerous  growth. 

The  occurrence  of  general  dissemination,  without  any  lymph 
gland  affection,  shows,  however,  that  cancer  cells  may  enter  the 
blood  otherwise  than  through  the  lymphatics ;  and  my  own 
belief  is  that  metastases  frequently  originate  in  this  way,  just  as 
they  do  in  sarcoma.  Hardly  ever  can  a  mammary  cancer  be 
examined  without  finding  the  veins  of  the  tumour  and  its 
vicinity  invaded  by  the  disease.  In  the  earliest  stage  the  venous 
wall  becomes  adherent  to  the  neoplasm  ;  then  it  gets  infiltrated, 


®'  Friedreich's  case  {Arch.  f.  path.  Anat.,  Bd.  xxxvi.,  S.  465)  of  cancerous  metas- 
tases in  the  left  knee  of  a  foetus,  whose  mother  died  of  cancer  of  the  liver  with  metas- 
tases during  the  pregnancy,  much  relied  upon  by  the  advocates  of  infection  by  the 
fluids  as  supporting  their  theory,  can  easily  be  accounted  for  by  the  embolic  theory. 


.  2o8  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

and  its  external  coat  perforated.  In  the  next  stage  the  new 
growth  projects  more  and  more  into  the  vein,  covered  only  by 
the  intima  of  the  latter.  This  soon  yields,  and  the  neoplasm — 
in  the  form  of  a  small  fungus — then  projects  into  its  lumen  ; 
whence  the  growth  may  be  detached  en  rnassey  or  in  minute 
fragments.  Cancer  emboli  of  this  kind  have  frequently  been 
found  free  in  the  blood  between  the  primary  seat  of  disease 
and  its  derivatives,  and  the  right  side  of  the  heart,  and  even  in 
the  latter  and  in  the  pulmonary  artery.  Several  trustworthy 
observers — Lucke  among  others*^- — maintain  that  they  have 
found  cancer  cells  free  in  the  blood.  That  cancer  emboli  may 
develop  into  cancerous  neoplasms,  the  well-known  facts  as  to 
the  auto-inoculability  of  the  disease  conclusively  prove  (Hahn's 
experiments,  &c.). 

We  have  now  to  enquire  what  it  is  that  determines  the 
development  of  metastatic  tumours  in  certain  localities  rather 
than  in  others.  There  can  be  no  doubt  that  the  dissemination 
of  cancer  emboli  is  regulated  by  the  same  mechanical  condi- 
tions that  determine  the  distribution  of  ordinary  emboli :  from 
the  veins  at  the  root  of  the  neck  they  pass  to  the  right  side 
of  the  heart,  thence  to  the  lungs  ;  whence  those  small  enough 
pass  through  the  pulmonary  capillaries,  and  so  into  the  left 
side  of  the  heart,  and  thence  into  the  aortic  system.  It  seems 
to  follow  from  this — since  the  pulmonary  capillaries  are  con- 
siderably smaller  ("007  to  "OOS  mm.)  than  most  cancer  cells 
('Oio  to  "050  mm.  and  upwards) — that  the  latter  must  almost 
invariably  be  arrested  first  of  all  in  the  lungs ;  and  consequently 
that  metastases  must  originate  there,  and  that  other  organs  can 
only  be  attacked  through  dissemination  thence.  But  such  con- 
clusions are  not  in  conformity  with  the  results  of  actual  obser- 
vation, which  show  that  the  liver  is  more  frequently  the  seat 
of  metastases  than  the  lungs ;  and  that  the  latter  often  escape, 
when  other  organs  arc  invaded,  whose  capillaries  are  larger  than 


*'  Haiidh.  d.  alli^.  u.  spec.  C/iii:,  1876. 


,  GENERAL    DISSEMINATION.  209 

those  of  the  lungs. ^'  These  and  other  phenomena  of  similar 
import,  indicate  that  the  formation  of  metastases  is  conditioned 
by  other  considerations  besides  those  of  mere  mechanical  dis- 
tribution. 

The  experiments  of  Maas  and  Cohnheim*^^  have  shown  that 
though  fragments  of  post-embryonic  tissues,  displaced  from 
their  normal  surroundings  and  introduced  into  the  bodies  of 
other  animals,  grew  at  first ;  yet,  after  a  time,  they  were  in- 
variably absorbed,  and  completely  disappeared.  The  reason  for 
this  evidently  is  that  the  foreign  structures  were  ultimately 
unable  to  withstand  the  metabolism  of  the  healthy  tissues. 
In  like  manner  I  suspect  most  cancer  emboli  perish ;  but 
because  some  organs  are  less  active  in  this  respect  than  others, 
therefore  they  are  more  frequently  affected  with  metastases. 
How  otherwise  can  we  explain  the  great  frequency  with  which 
the  liver  is  affected,  and  the  remarkable  relative  immunity  of 
the  spleen,  both  organs  being  equally  exposed  to  the  incidence 
of  cancer  emboli  ?  That  cancer  emboli  frequently  survive  and 
develop  into  secondary  tumours,  in  spite  of  the  resistance  of 
the  tissues,  evidently  must  be  due  either  to  their  abnormal  in- 
herent activity,  or  to  falling  off  in  the  physiological  capacity  for 
resistance  of  the  tissues,  x^ccording  to  Cohnheim,  it  is  wholly 
and  solely  due  to  the  latter.  In  this  I  cannot  concur.  The 
experiments  of  Zahn^'^  and  Leopold^*'  appear  to  me  to  point 
the  other  way.  They  have  shown  that  transplanted  grafts  of 
embryonic  tissues  survive  in  spite  of  the  physiological  resist- 
ance, even  to  the  extent  of  increasing  200  or  300  times  in  size. 
This  is  clearly  due  to  the  inherent  activity  of  their  constituent 
cells;  and,  as  I  have  previously  shown,  it  is  with  embryonic 


*'  The  passage  of  cancer  emboli  through  the  lungs,  in  spite  of  the  above-men- 
tioned difficulties,  becomes  intelligible  when  we  consider  the  velocity  of  the  flow,  the 
distensibility  of  the  capillaries,  and  the  smallness  oi  young  cancer  cells,  which  often 
measure  considerably  less  than  the  figures  given  above. 

"^  Arch.  f.  path.  Anat.,  Bd.  Ixx.,  S.  161. 

^'  Sur  le  sort  des  tissues  implantes  dans  I'organisme,  Cong.  nied.  internat.  de 
Geneve,  1878. 

**  Arch. /.path.  Anat.,  Bd.  Ixxxv.,  S.  283. 

H 


2IO  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

rather  than  with  post-embryonic  tissues,  that  actively  growing 
cancer  structures  are  comparable. 

From  the  foregoing  it  will  be  gathered  that  the  ultimate  fate 
of  a  cancer  embolus — its  complete  absorption  or  its  develop- 
ment into  a  secondary  cancerous  growth — depends  mainly  upon 
whether  the  inherent  vital  activity  of  its  constituent  cells,  is 
strong  enough  to  resist  successfully  the  phagocytic  action  of  the 
part  of  the  body  in  which  it  has  lodged,  or  not. 

&     V  1 1 . Cachexia. 

Consideration  of  the  phenomena  of  cachexia  naturally  follows 
that  of  dissemination,  because,  as  I  shall  proceed  to  show,  just  as 
the  latter  depend  upon  the  entry  of  living  cancer  cells  into  the 
circulation,  so  the  former  likewise  depend  upon  the  entry  into 
the  circulation  of  the  products  resulting  from  their  disintegration. 

After  a  cancerous  growth  has  existed  in  the  breast  for  a 
variable  time,  which  is  generally  rather  long,  the  patient's  health 
begins  to  suffer — even  in  the  absence  of  ulceration,  haemorrhage, 
&c.  Pallor,  weakness,  emaciation  and  loss  of  appetite,  are  among 
the  most  obvious  manifestations.  These,  as  the  disease  pro- 
gresses, become  greatly  aggravated — the  pallor  taking  on  a 
peculiar  earthy  or  straw-coloured  tint — while  other  indications 
of  profound  disturbance  of  the  general  nutrition  arise  ;  which, 
when  the  malady  runs  its  natural  course,  eventually  determine 
death  from  asthenia. 

The  condition  thus  briefly  sketched  is  that  generally  known 
as  the  cancerous  cachexia.  As  a  rule  it  is  more  typically 
developed  in  connection  with  breast  cancers,  than  with  those  of 
most  other  parts  of  the  body  ;  yet  in  the  tubular  and  colloid 
varieties  of  mammary  cancer  it  is  seldom  seen.  Sarcomatous 
tumours  very  rarely  cause  it,  and  non-malignant  ones — even  the 
largest — never.  Hence  the  condition  evidently  cannot  be 
attributed  to  the  mere  abstraction  of  nutritive  materials  from 
the  blood,  as  some  have  suggested. 

It  is  a  noteworthy  fact  that  cachectic  symptoms  never  pre- 


CACHEXIA.  211 

cede  the  outbreak  of  the  primary  disease  ;  from  this  we  may 
infer  that  they  are  a  consequence  of  its  local  progress.  Certain 
it  is  that  after  remoyal  of  the  disease  by  operation  the  cachectic 
symptoms  often  disappear,  and  in  the  absence  of  recurrence, 
patients  may  retain  their  healthy  appearance  for  several  years, 
as  in  cases  I  have  observed.  The  degree  of  cachexia  is,  however, 
by  no  means  always  proportionate  to  the  mere  extent  of  the 
local  malady,  for  I  have  seen  well-marked  cachectic  symptoms 
supervene  acutely,  at  an  early  stage,  when  the  primary  disease 
has  been  quite  small.  Neither  can  it  be  maintained  that  cachexia 
is  dependent  upon  dissemination,  for  it  may  be  absent  when  the 
latter  is  very  marked,  and  vice  versa.  In  certain  exceptional 
cases  cancer  of  the  breast  may  even  run  its  entire  course  without 
ever  causing  any  cachexia,  or  other  very  obvious  disturbance  of 
the  general  nutrition,  the  patients  being  able  to  follow  their 
usual  avocations  almost  to  the  last.  The  date  at  which  cachectic 
symptoms  supervene,  their  sequence,  and  degree  of  development 
are  so  exceedingly  variable,  that  nothing  definite  can  be  stated 
in  respect  to  them. 

We  may,  I  think,  best  interpret  these  symptoms  as  the  result 
of  a  general  toxaemia,  the  explanation  of  which  must  be  sought 
in  the  remarkable  proneness  of  the  constituent  cells  of  breast 
cancers  to  undergo  granulo-fatty  degeneration,  which  is  often  so 
extreme  as  to  lead  to  their  complete  destruction  by  disintegra- 
tion. When  such  excrementitious  products  find  their  way — by 
nutritive  absorption  or  otherwise — into  the  general  circulation, 
in  quantities  too  great  to  be  quickly  eliminated  and  destroyed, 
they  poison  the  fluids  of  the  body,  and  so,  by  a  kind  of  auto- 
intoxication, similar  to  that  by  which  the  system  is  infected  from 
an  inflammatory  focus,  they  originate  the  phenomena  of  the 
cancerous  cachexia.  Hence  these  symptoms  are  much  more 
frequently  met  with  in  association  with  cancers,  whose  cells  are 
especially  prone  to  degenerative  disintegration,  than  with  those 
whose  cellular  elements  are  more  stable.  It  seems  probable, 
from  the  experiments  of  Adamkiewicz,*^^  that  the  excrementitious 

"'  Untersuchungen  uber  den  Krebs,  Sec,  Vien,  1893. 


2  12  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

products  thus  produced  contain  toxines,  analogous  to  the  viru- 
lent substances  secreted  by  microbes. 

Through  these  agencies  the  blood  of  cancer  patients  gets 
profoundly  modified  both  morphologically  and  chemically. 
Hayem^^  and  others  have  found  marked  leucocytosis,  the 
number  of  white  corpuscles  being  increased,  according  to 
Hayem,  from  6,000  per  cubic  millimetre — the  normal  standard 
— to  1 1,400  in  breast  cancer  patients.  Its  poverty  in  haemoglobin 
has  been  demonstrated  by  Ouinquad  :"^  1,000  grammes  of  blood 
normally  contain  about  125  grammes  of  this  substance,  whereas 
in  cancer  patients  the  amount  often  does  not  exceed  25  grammes. 
Nothing  comparable  to  this  is  met  with  in  cases  of  sarcoma  and 
non-malignant  neoplasms.  Laker^°  maintains  that  the  difference 
between  cancerous  and  non-cancerous  blood  in  this  respect  is  so 
marked  and  constant,  that  it  may  be  relied  on  for  the  purpose 
of  differential  diagnosis.  Andral  and  Simon  long  ago  showed 
that  in  cancer  patients  the  relative  number  of  red  corpuscles  is 
diminished — even  in  the  absence  of  ulceration  and  haemorrhage 
— and  these  results  have  been  confirmed  by  Ardle  and  others. 
The  quantity  of  albumen  dissolved  in  the  serum  is  also  less  than 
normal.  To  these  causes  may  be  attributed  the  diminished 
specific  gravity  of  the  blood.  Hence  also  the  tendency  in  ad- 
vanced cachexia  to  passive  serous  effusions — hydrothorax 
anasarca,  &c. — as  well  as  to  venous  thromboses.  According  to 
Freund^^  an  excess  of  sugar  in  the  blood  is  of  constant  occur- 
rence in  cancer. 

Not  only  are  the  morphological  and  chemical  constituents  of 
the  blood  thus  altered,  but  the  experiments  of  Louis^-  show  that 
its  total  quantity  is  notably  diminished.  This  affords  a  ready 
explanation  of  the  smallness  of  the  heart  and  aorta,  observed 


'■'  C.  R.  de  la  Soc.  de  Biol.,  1887,  t.  iv. ,   p.   270  ;    see  also  his  work,  "  Du  Sang,' 
Paris,  1889. 

*"  Chimie  palhologicjue. 

""  Cent.f.  d.  vied.  Wissemchaft,  1887,  S.  405. 

"'   "  Zur  Diagnose  des  Carcinoms,"  Wiener  med.  Blatter,  No.  9,  1885. 

^  "  Researciies  on  Phthisis,"  Walshe's  iransl.,  1846,  pp.  52,  54. 


CACHEXIA.  213 

post-mortem,  in  most  cancer  cases  that  have  run  their  natural 
course  ;  although,  as  Beneke^^  has  shown,  prior  to  the  outbreak 
of  the  disease,  cancer  patients  have  large  hearts  and  blood 
vessels.  Similar  changes  occur  in  the  course  of  other  chronic 
wasting  diseases,  especially  in  phthisis. 

One  of  the  most  obvious  manifestations  of  this  depraved  state 
of  the  blood  is  pallor  of  the  skin,  which,  as  the  disease  pro- 
gresses, often  assumes  a  waxy,  puffy  aspect,  together  with  the 
peculiar  straw-coloured  tint,  so  characteristic  of  the  cancerous 
cachexia.  A  somewhat  similar  condition  may  arise  in  certain 
stages  of  chlorosis  and  pernicious  ansemia.  From  jaundice  it 
differs  in  that  it  affects  chiefly  the  skin — the  mucous  and 
synovial  membranes  and  urine  escaping.  To  the  same  cause 
may  be  attributed  the  haemic  murmurs  so  often  audible  over 
the  heart  and  large  vessels.  A  later  developed  manifestation  is 
emaciation,  which,  when  it  has  once  set  in,  is  steadily  progressive, 
so  that  the  wasting  is  often  extreme.  This,  like  most  of  the 
other  individual  symptoms  of  the  cancerous  cachexia,  may, 
however,  occasionally  be  absent. 

Gastro-intestinal^\?>'oxx\izx\CQ.  is  commonly  experienced.  Loss 
of  appetite,  dyspepsia,  anorexia,  together  with  thirst,  are  often 
prominent  symptoms.  Nausea  and  vomiting  are  also  of  fre- 
quent occurrence,  even  in  the  absence  of  visceral  dissemination  ; 
and  slight  jaundice  is  not  uncommon.  Constipation  oftener 
exists  than  diarrhoea. 

Quasi-rheumatic  pains  in  various  parts  of  the  body,  remote 
from  the  primary  seat  of  disease,  such  as  the  loins,  hips,  lower 
limbs,  &c.,  are  often  complained  of.  When  these  coincide  with 
subacute  febrile  disturbance,  as  occasionally  happens,  the  condi- 
tion may  easily  be  mistaken  for  subacute  rheumatism,  of  which 
I  have  seen  several  instances.  Often  pains  of  a  neuralgic 
character  are  experienced,  as  well  as  numbness  and  tingling  of 
the  hands,  feet,  &c. 

Those  who  have  examined   cancer   patients  for  peripheral 

"'  "  Constitution  und  constitutionelles  Kranksein  des  Menschen,"  Marburg,  1887. 


2  14  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

neuritis  have  generally  found  it — e.g.,  Gombault,  KHppel, 
Arthaud,  Auche,^*  Isch-Wall,^^  &c.  Other  observers  (Cuffer, 
Riehl,  &c.)  have  described  various  visceral  vaso-motor  disturb- 
ances, which  they  attribute  to  inflammation  of  the  sympathetic 
nerves. 

In  a  few  cases,  after  the  disease  has  existed  for  a  consider- 
able time,  cancer  patients  become  insane ;  the  form  of 
mental  derangement  I  have  most  frequently  seen  is  that  of 
dementia.  PineP*^  mentions  a  case  of  this  kind  in  which  the 
insanity  was  cured  by  removal  of  the  cancerous  disease. 

Alterations  in  the  blood  that  involve  considerable  reduction 
in  its  haemoglobin,  as  in  phthisis,  chlorosis,  anaemia,  &c.,  are 
usually  associated  with  widespread  fatty  degeneration,  the  result 
of  impaired  oxidation  from  diminished  supply  of  oxygen.  The 
cancerous  cachexia  is  no  exception  to  this  rule ;  but  it  is  not 
until  emaciation  has  made  marked  progress  that  these  changes 
set  in.  The  parts  most  obviously  affected — to  the  naked  eye — 
in  breast  cancer,  are  the  liver,  kidneys,  aortic  arch,  blood  vessels, 
heart,  &c.  ;  but  histological  examination  shows  that  these 
changes  are  not  limited  to  the  above-mentioned  localities — they 
affect  most  parts  of  the  body,  especially  the  gastric  mucous 
membrane. 

A  remarkable  fact  that  may  be  mentioned  here,  is  the  rarity 
of  amyloid  degeneration  in  association  with  cancer;  there  was  not 
a  single  instance  of  it  in  the  forty-four  necropsies  on  breast 
cancer  patients  analysed  by  me. 

From  the  general  malnutrition  consequent  on  the  cancerous 
toxaemia,  the  bones  suffer  as  well  as  the  other  structures.  Great 
interest  attaches  to  these  little  studied  changes,  which  require  to  be 
carefully  discriminated  from  the  lesions  produced  by  cancerous 
dissemination,  with  which  most  pathologists  have  confounded 
them.     According  to  my  experience  the  bones  most  frequently 

"'  Revue  de  Med.,  1890,  p.  785.  "  Des  nevrites  perpheriques  chez  les  can- 
cereuses." 

"■■  "Cancer  et  Arthritisme,"  These  de  Paris,  No.  147,  1890,  p.  119. 
""  "Tiaile  de  Path.  Cerebrale,''  p.  224. 


CACHEXIA.  215 

thus  affected  in  a  marked  degree  are  the  ribs^  sternum,  femur, 
humerus,  and  vertebrce.  These  when  affected  still  retain  their 
normal  size  and  shape  ;  but  they  are  lighter  and  more  fragile  than 
they  should  be,  so  that  they  are  easily  fractured.  There  is  thin- 
ning of  the  cortex,  with  increased  size  of  the  medullary  canal,  and 
relative  deficiency  of  inorganic  salts.  The  Haversian  canals  and 
cancelli  are  much  enlarged,  and  filled  with  diffluent  fatty  matter, 
hence  the  undue  porosity.  There  is,  however,  no  softening  from 
decalcification  as  in  osteo-malacia.  Altogether  the  indications 
point  to  defective  deposition  of  new  bone,  to  replace  the  normal 
loss  by  absorption,  as  the  proximate  cause  of  the  disease.  The 
condition  seems  to  have  many  analogies  with  the  bone  degenera- 
tion of  the  insane  and  of  the  senile.  Owing  to  this  fragility  of 
the  bones,  so-called  spontaneous  fractures  are  easily  determined, 
as  in  the  following  cases  : — 


(i)  A  pale  woman,  aged  53,  came  under  my  observation  with  recurrent 
scirrhous  cancer  of  the  right  mammary  region.  Between  the  amputation, 
scar  and  the  outer  third  of  the  clavicle  was  a  hard,  fixed,  nodular  mass, 
adherent  to  the  overlying  skin.  The  right  upper  limb  was  oedematous  and 
useless,  and  the  axillary  glands  were  extensively  involved.  There  was  an 
ununited  fracture  of  the  upper  part  of  the  right  femur,  accompanied  by  great 
swelling,  which  resulted  from  spontaneous  fracture  three  months  previously. 
Five  years  ago  the  primary  disease  began  as  a  small  hard  lump  in  the  upper 
segment  of  the  right  breast.  Three  years  later  the  diseased  part  was  ampu- 
tated, and  one  year  ago  the  present  recurrence  set  in.  No  further  operation 
was  done,  and  the  patient  died  of  pulmonary  complications  some  nine 
months  later.  At  the  necropsy  an  old  ununited  fracture  of  the  upper  third 
of  the  right  femur  was  found,  with  angular  displacement  of  the  fragments, 
the  ends  of  which  were  embedded  in  a  large  mass  of  partially  ossified  callus  ; 
there  was  a  similar  fracture  of  the;  left  femur.  In  moving  the  body  the  right 
humerus  fractured  just  above  the  elbow  joint.  The  ribs  and  sternum  were 
very  brittle.  Longitudinal  sections  were  made  of  all  these  bones  and  of 
several  others  ;  but  no  sign  of  cancerous  growth  could  be  found  in  connec- 
tion with  any  of  them.  The  cortex  of  each  was  very  thin  ;  the  medullary 
cavity  greatly  enlarged  was  full  of  diffluent  fatty  substance.  The  cancerous 
growths  in  the  mammary  region  and  axilla  were  of  a  hard,  crisp,  scirrhous 
nature.  The  former  had  penetrated  the  chest  wall  and  invaded  the  upper 
part  of  the  right  pleura;  this  had  caused  hydrothorax  and  collapse  of  the 
right  lung.  The  oedema  of  the  right  upper  limb  was  caused  by  the  pressure 
of  cancerous  glands  upon  the  axillary  vein.  The  liver  contained  several 
cancerous  nodules. 


2l6  THE    MORPHOLOGY    OF    MAiMMARY    CANCER. 

(2)  A  woman,  aged  47,  with  atrophic  scirrhus  of  the  left  breast,  and 
infiltration  of  the  axillary  and  supra-clavicular  glands.  At  the  necropsy  a 
secondary  nodule  was  found  in  the  right  kidney.  There  were  double  spon- 
taneous fractures  of  four  ribs  on  the  right  side  ;  and  two  similar  rib  fractures 
on  the  left  side — one  double  and  the  other  single.  There  were  no  secondary 
cancerous  growths  at  the  seats  of  fractures.  The  right  ventricle  of  the  heart 
was  in  advanced  fatty  degeneration.  The  lungs  were  emphysematous  and 
congested. 

(3)  In  the  museum  of  University  College,  London,  there  is  a  specimen 
of  this  disease,  which  is  described  in  the  catalogue  as  follows  :^'  "Longitu- 
dinal section  of  humerus,  the  shaft  of  which  was  fractured  a  short  distance 
below  its  middle,  by  the  patient  turning  in  bed.  A  ring  of  porous  osseous 
tissue  has  been  formed  around  and  unites  the  end  of  the  fragments,  the 
compact  walls  of  which  are  coarsely  reticulated  from  inflammation  accom- 
panying the  reparative  process.  A  second  fracture  had  occurred  about  one 
and  a  half  inches  below  the  preceding,  and  had  firmly  united,  the  medullary 
canal  being  still  filled  with  osseous  substance.  The  osseous  tissue  has 
throughout  a  friable  chalky  appearance,  and  towards  its  upper  end  the  bone 
is  considerably  atrophied.  From  a  woman  who  was  extensively  affected 
with  cancer.  There  is  no  appearance  of  the  humerus  itself  having  been  the 
seat  of,  or  invaded  by  any  morbid  growth."' 

De  Morgan-'''  mentions  a  similar  case  in  which  the  bodies  of  several 
vertebrae  completely  disappeared. 

Torok  and  Wittelshofer^^  met  with  the  like  osseous  lesions 
in  eight  of  their  366  necropsies  on  patients  dead  of  breast 
cancer.  Rokitansky,  LUcke,  Billroth,  and  others  have  also 
described  cases  of  this  kind. 

When  ulceration  sets  in,  and  the  wound  gets  invaded  by 
microbes,  the  ordinary  symptoms  of  septic  infection  are  super- 
added to  those  of  the  cancerous  cachexia.  Consequent  suppu- 
ration and  hsemorrhage  further  weaken  the  patient.  At  length, 
if  not  cut  off  by  some  intercurrent  disease,  death  results  from 
asthenia,  as  happened  in  twenty-four  out  of  forty  cases  that  ran 
their  natural  course  under  my  observation. 


"'  "Catalogue  <jf  Surgical  Pathology,"  part  i.,  1881,  p.  5. 

**  "On  the  Origin  of  Cancer,"  1872. 

"•  "  Zur  Slatistik  des  niamina  Carcinoms,''  A>\h.  f.  klin.  Chir.,  Bd.  xxv.,  S.  873, 


1881. 


RECURRENCE.  217 

&     V  1 1 1 . Recurrence. 

No  feature  of  cancer  has  attracted  more  attention  than  that 
which  is  known  as  "  recurrence."  It  certainly  does  seem  extra- 
ordinary, after  everything  has  been  done  to  ensure  its  destruc- 
tion— whether  by  the  knife,  by  fire  or  by  caustics — that  the 
disease  should,  nevertheless,  so  frequently  spring  up  again. 
Before  attempting  to  explain  this  remarkable  phenomenon, 
I  propose  briefly  to  set  forth  the  chief  known  facts  relating 
to  it. 

In  the  great  majority  of  these  cases  the  recurrent  disease 
makes  its  first  appearance  in  the  locality  occupied  by  the 
primary  disease,  less  frequently  in  the  adjacent  lymph  glands, 
and — rarest  of  all — in  remote  parts  of  the  body. 

Thus  of  forty-seven  recurrent  mammary  cancers  under  my 
observation,  the  disease  first  reappeared  in  the  primarily  affected 
mammary  region  in  twenty-one  cases;  in  the  mammary  region 
and  in  the  axillary  glands,  at  about  the  same  time,  in  eighteen 
cases ;  and  in  the  axilla  alone  in  eight  cases. 

According  to  Gross, ^^'^  of  496  local  recurrences — 

294  or  59'27  per  cent,  were  in  the  mammary  region  alone. 
ii7or23"59         „  „  mammary  region  and  the  ad- 

jacent lymph  glands. 
77  or  1 5*50         „  „  adjacent  lymph  glands  alone. 

8  or    I '6 1         „  „  opposite  breast. 

Thus  of  these  543  recurrent  cases  the  disease  was  situated  in 
the  mammary  region  in  about  83  per  cent. ;  and  in  the  axilla 
alone  in  about  15  per  cent. 

Recurrences  in  the  mammary  region,  when  first  noticed, 
usually  present  as  small  nodules — from  three  to  six  or  more  in 
number  ;  their  initial  situation  being  either  in  the  operation  scar 
or  its  immediate  vicinity,  or  in  the  subjacent  muscle — rarely 
elsewhere. 

Reappearance  of  the  disease  in  parts  of  the  body  not  directly 
connected   with   the  primary   neoplasm  or    its  derivatives   (so- 


'■-  Am.  Syst.  Gyn.,  vol.  ii.,  p.  301. 


2l8 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


called  metastatic  recurrence),  was  found  by  Gross  to  have  taken 
place  in  178  out  of  1,036  cases,  or  in  17  per  cent. ;  but  in  129  of 
these  cases  there  was  local  or  lymph  gland  recurrence  as  well. 

The  period  at  which  recurrences  first  present  is  exceedingly 
variable;  and  the  numerical  results  obtained  by  different  investi- 
gators are  often  divergent.  Of  forty-seven  consecutive  cases 
under  my  observation,  the  average  interval  between  the  opera- 
tion and  the  first  obvious  recurrence  was  twenty-six  months,  the 
maximum  130  months,  the  minimum  a  few  weeks.  These 
results  are  more  favourable  than  those  arrived  at  by  my  pre- 
decessors. According  to  Gross,  the  average  period  of  immunity 
only  amounts  to  9*4  months. 

T  have  compiled  the  following  table,  based  on  599  cases,  to 
show  the  periods  at  which  recurrence  may  be  expected. 


Interval  between  operation  and  first 

obvious  recurrence. 


Author's 

Paget's 

Gross' 

Total 

47  cases. 

74  cases. 

478  cases. 

599  cases 

4 

23 

211 

a,,8 

8 

22 

87 

117 

9 

14 

106 

129 

10 

7 

47 

64 

6 

3 

16 

25 

10 

5 

II 

26 

Per 

cent. 


Under  3  months 
3  to  6  months  ... 
6  to  12  months 
12  to  24  months 

2  to  3  years 

Over  3  years    ..., 


397 
19-5 
21-5 
IO-8 
4-2 
4-3 


From  this  we  learn  that  nearly  60  per  cent,  of  all  recurrences 
take  place  within  the  first  six  months  after  operation  ;  and  of 
these  40  per  cent,  originate  within  the  first  three  months. 
According  to  Gross,  22  per  cent,  occur  within  the  first  month, 
and  8-9  per  cent,  within  the  first  fifteen  days.  The  propor- 
tion of  recurrences  attributed  by  Winiwarter  to  the  first  month 
is  even  higher  than  this.  On  the  other  hand,  only  43  per 
cent,  of  all  recurrences  originate  after  three  years. 

Occasionally  recurrence  sets  in  immediately  after  operation, 
as  in  the  following  case  : — 

A  stout,  healthy- looking  woman,  aged  68,  with  very  large  mammje,  came 
under  my  observation  with  a  movable  tumour — of  three  months  growth — 
the  size  of  a  turnip,  in  the  middle  of  her  right  breast.  There  was  no 
obvious  affection  of  the  axillary  lymph  glands.  The  breast  was  ainputated 
without  opening  the  a.xilla.     Immediately  afterwards  acute  diffuse  recurrence 


RECURRENCE.  2ig 

set  in,  which  involved  the  whole  wound.  The  skin,  pectoral  and  intercostal 
muscles,  ribs  and  pleura,  were  quickly  infiltrated.  Six  weeks  after  opera- 
tion, death  ensued  from  hydrothorax  and  collapse  of  the  right  lung,  owing  to 
direct  extension  of  the  disease  through  the  chest  wall.  At  the  necropsy  the 
right  parietal  pleura  was  found  to  be  studded  throughout  with  cancerous 
nodules  ;  and  it  showed  signs  of  recent  acute  inflammation.  The  diaphragm 
and  liver  contained  numerous  secondary  growths,  but  none  were  present  in 
either  of  the  lungs,  nor  in  the  left  pleura.  It  was  a  case  oi  acute  traumatic 
malignancy  after  operation. 

At  other  times  recurrence  is  delayed  for  many  years — even 
for  from  twenty  to  thirty  years.  According  to  Nunn,^'^^  on  the 
average  one  in  thirteen  of  all  operated  cases  remains  free 
from  recurrence  for  from  ten  to  twenty  years.  Of  the  forty- 
seven  recurrent  cases  in  my  list  there  were,  however,  only  two 
instances  in  which  the  period  of  immunity  had  extended  to  ten 
years.  A  striking  example  of  tardy  recurrence  is  afforded  by 
members  of  the  family,  whose  history  Sibley^°^  has  recorded,  in 
which  the  mother  and  her  five  daughters  all  had  cancer  of  the 
left  breast.  Two  of  these  sisters  passed  eleven  and  twelve  years 
respectively,  after  removal  of  the  primary  disease,  without 
recurrence  ;  and  upon  its  return  at  those  dates  and  repetition 
of  the  operation,  each  remained  free  from  its  return  for  seven 
years  more,  and  they  were  still  free  when  last  heard  of. 

The  two  following  cases  of  late  recurrence  have  come  under 
my  own  observation. 

Case  I. — An  emaciated  woman,  aged  62,  with  a  large  hard  mass  of 
ulcerated  recurrent  cancer  in  the  right  mammary  region,  and  cancerous 
glands  in  the  axilla  and  lower  part  of  the  neck.  About  twelve  years  ago 
she  first  noticed  a  lump  in  her  right  breast,  which  was  amputated  soon 
afterwards.  Ten  years  subsequently  several  small  recurrent  nodules 
appeared  in  the  vicinity  of  the  scar  and  in  the  axilla.  Two  years  ago  these 
were  excised.  Six  months  later  the  present  recurrence  set  in.  No  further 
operation  was  done.  She  died  of  pulmonary  complications,  apparently  due 
to  invasion  of  the  chest  by  the  local  disease,  some  two  and  a  half  months 
later. 

Case  II.— A  well-nourished,  healthy-looking  woman,  aged  58,  with  a 
nodule  of  atrophic  recurrent  cancer — the  size  of  a  hazel  nut — at  about  the 
middle  of  the  old  scar  in  the  left  mammary  region  ;  and  no  obvious  enlarge- 

""  "  Cancer  of  the  Breast,"  1882,  p.  45. 
"*  Med.  Chir.  Trans.,  vol.  xlii.,  p.  III. 


2  20  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

merit  of  the  axillary  glands.  Twenty  years  ago  she  first  noticed  a  small 
hard  lump  in  the  middle  of  her  left  breast.  It  slowly  increased.  Ten  years 
later  the  breast  was  amputated.  She  remained  quite  free  from  any  return 
of  the  disease  until  six  months  ago,  when  the  present  recurrence  was  first 
noticed.     It  was  excised,  and  the  wound  had  healed  a  fortnight  later. 

The  following  highly  remarkable  instances  of  this  kind  have 
been  reported  by  others. 

Bryant'"''  has  related  the  history  of  a  woman,  about  the  age  of  38,  who 
underwent  amputation  of  the  breast  for  primary  cancer  of  five  years'  dura- 
tion ;  and  subsequently  remained  free  from  recurrence  for  twenty-five  years, 
when  there  was  return  of  the  disease  in  the  scar,  &c.  A  daughter  of  hers 
died,  aged  50,  of  acute  mammary  cancer  of  only  six  months'  duration.  In 
another  case  by  the  same  surgeon,  the  patient,  aged  44,  remained  free  from 
recurrence  for  twenty-three  years  after  extirpation  of  the  primary  disease, 
when  recurrence  appeared  in  the  vicinity  of  the  old  scar. 

In  a  patient  of  Nunn's,""'  aged  37,  there  was  immunity  from  return  for 
sixteen  years,  when  the  disease  reappeared  in  the  scar. 

The  longest  period  of  immunity  hitherto  recorded  is  in  a  case  by 
Verneuil,'"  in  which  the  disease  recurred  in  situ  thirty  years  after  ampu- 
tation of  the  breast  for  the  primary  cancer.  Both  the  primary  and 
secondary  growths  were  submitted  to  careful  histological  examination,  and 
the  appearances  they  presented  were  those  of  ordinary  scirrhous  cancer. 

The  foregoing  cases  admirably  illustrate  the  extraordinary 
differences  that  obtain  in  relative  malignancy,  between  cancers 
of  the  same  variety — morphologically  indistinguishable — in  the 
same  locality,  and  apparently  under  similar  conditions. 

Careful  examination  of  recurrent  growths  reveals  the  im- 
portant fact,  that  in  both  their  morphological  and  pathological 
characters  they  precisely  resemble  the  primary  neoplasm.  From 
this  we  may  infer  either  that  recurrences  originate  from  the 
primary  neoplasm  or  its  derivatives,  or  that  both  spring  from 
the  same  source — the  mammary  gland  itself  These  are  in  fact 
the  sole  sources  of  recurrent  growths.  Very  significant  is  it 
that  the  great  majority  of  recurrences  are  situated  in  the  mam- 
mary region,  either  in,  or  in  the  immediate  vicinity  of  the  opera- 
tion wound.  The  histological  researches  of  Heidenhain  and 
others  have  conclusively  demonstrated,  that  fragments  of  the 


"^  "  Diseases  of  the  Breast,"  p.  158. 

'«  Op.  cit. 

"'  La  Shnaine  inedicaU,  i8bS,  p.  112. 


RECURRENCE. 


221 


original  disease  are  almost  invariably  left  behind  after  operations 
undertaken  for  its  removal,  as  hitherto  usually  practised.  Taken 
altogether  the  foregoing  considerations  point  to  these  morbid 
fragments  as  the  germs  whence  most  recurrent  growths  originate. 
Thus  may  be  explained  the  initial  vuiltiplicity  of  most  recur- 
rences, wherein  they  differ  so  markedly  from  independent  spon- 
taneous outbreaks  which  are  almost  invariably  solitary. 


Fig.  41. — Recurrent  mammary  cancer  {Hutchinsofi). 


The  great  frequency  of  recurrences  soon  after  operations 
points  in  the  same  direction.  Hence  we  may  conclude  that 
the  immense  majority  of  local  recurrences  are  due  to  incomplete 
ablation  of  the  primary  growth.     In  these  cases  there  is  indeed 


2  22  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

no  real  reproduction  of  the  disease,  but  merely  continuation  of  it 
in  the  surviving  unextirpated  fragments  {continuation  recurrence). 
Similarly,  when  after  operation  the  disease  recurs  in  adjacent 
lymph  glands,  or  in  remote  parts  of  the  body — apparently 
unaffected  before — we  may  infer  that  its  recrudescence  in  these 
situations  is  generally  due  to  the  dissemination  there  of  frag- 
ments of  the  primary  disease,  prior  to  the  operation  for  its 
removal,  which  have  subsequently  developed  as  in  the  formation 
of  other  disseminative  growths. 

Yet  there  are  some  late  local  recurrences — of  which  several 
instances  have  been  described  above — that  cannot  be  explained 
in  this  way.  These  cases,  which  are  rare,  are  I  think  un- 
doubtedly due  to  independent  outbreaks  of  the  disease  {repullu- 
lation)  in  unextirpated  remains  of  the  mammary  gland  itself, 
which,  as  Heidenhain  has  shown,  are  never  in  a  normal  condi- 
tion. This  last  fact  explains  the  almost  invariable  localisation 
of  these  late  recurrences  in  the  affected  mammary  region  rather 
than  elsewhere.^*^^ 

I  have  also  met  with  certain  cases  of  late  return  of  the 
disease  in  the  axilla,  which  I  think  cannot  be  explained  as 
continuation  recurrences,  e.g. — 

(i)  A  woman,  aged  59,  first  noticed  a  cancerous  tumour  in  her  left  breast 
nine  years  ago.  Seven  years  ago  the  part  was  amputated,  but  the  axilla 
was  not  touched.  She  remained  quite  free  from  any  return  of  the  disease 
until  two  months  ago,  when  a  hard  cancerous  lump  formed  at  the  upper  and 
inner  part  of  the  left  axilla  ;  the  scar  in  the  mammary  region  and  its 
vicinity  being  quite  free. 

(2)  In  a  patient,  aged  48,  four  years  after  amputation  of  her  right  breast 
for  hard  cancer,  the  disease  reappeared  in  the  right  axilla,  the  scar  in  the 
mammary  region  and  its  vicinity  being  quite  healthy.  At  the  primary 
operation  the  axilla  was  not  touched. 

I  have  elsewhere'''^  directed  attention  to  the  almost  invari- 
able occurrence  of  extensions  of  the  mammary  gland  into  the 
axilla,  which  are  often  completely  sequestrated  ;  and  to  the 
frequency  with   which  neoplasms  originate  from  these  axillary 

'""   For  some  additional  cases,  vide  <Z\\.  x.,   §  9. 

""'  fonrnal  of  Anatomy,  vol.  xxv.,  p.  253  ;  also  Ch.  iv.,  §  v. 


RECURRENCE.  223 

mammary  sequestrations.  In  the  foregoing  cases  I  think  we  have 
to  do  with  independent  outbreaks  of  the  disease  in  such  out- 
lying extensions  or  sequestrations  left  behind  at  the  time  of 
operation.  In  like  manner  primary  axillary  cancers  arise.  It 
is  probable  that  certain  cases  of  late  recurrence  in  the  mam- 
mary region,  arising  at  some  distance  from  the  operation  scar, 
have  also  a  similar  origin. 

Second  recurrences  are  fairly  common.  I  have  met  with 
them  in  eight  out  of  forty-three  recurrent  cases  ;  the  earliest 
appeared  a  few  weeks  after  the  operation;  the  latest  130 
months,  and  the  average  interval  was  23"2  months.  In  these 
same  eight  cases  the  period  of  onset  of  the  first  recurrence 
averaged  a^v^  months.  This  supports  Thiersch's  dictum,  that 
the  interval  between  operation  and  recidivity  tends  to  shorten 
with  each  successive  operation. 

Third  recurrences  are  rare ;  there  was  only  one  instance  of 
the  kind  among  the  forty-three  recurrent  cases  of  my  list. 

Lastly,  it  seems  not  improbable  that  local  recurrences  are 
sometimes  due  to  wound  infection  from  the  dissemination  of 
cancerous  fragments,  &c.,  detached  by  the  surgeon's  knife  during 
operation.  To  avoid  this  Donitz^^^  recommends  that  care  should 
be  taken  not  to  cut  into  such  neoplasms  during  their  removal. 

o     I  yC. Inflammation,  Gangrene,  Ulceration,  Degenerative  Metamorphoses, 

Retrogression,  the  Question  of  Spontaneous  Cure,  &c. 

Cancerous  neoplasms  once  formed  live  and  are  nourished  like 
normal  parts  of  the  body  ;  yet  they,  in  return  for  the  nutriment 
thus  supplied,  contribute  nothing  serviceable.  Nerveless, 
functionless,  and  redundant,  their  relationship  to  the  rest  of  the 
organism  differs  but  little  from  that  of  parasitism. 

The  biology  of  cancers,  like  that  of  normal  parts,  is  con- 
ditioned mainly  by  the  inherent  properties  of  their  constituent 
cells,  and,  in  a  less  degree,  by  their  blood  suppl}'.  Hence  the 
same  elementary  pathological  disturbances  may  be  witnessed  in 


Berlin  klin.  Woch.,  No.  27,  1888,  S.  544. 


2  24  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

them  as  in  the  breast  itself — e.g.,  congestion,  inflammation,  sup- 
puration, gangrene,  ulceration,  and  the  degenerative  metamor- 
phoses. That  long-continued  augmentation  of  the  blood  supply 
may  accelerate  the  growth  of  cancers,  and  diminished  blood 
supply  retard  it,  is,  I  think,  indisputable.  The  marked  exacer- 
bation of  mammary  cancers,  consequent  on  pregnancy,  traumata, 
and  various  irritants  are  examples  of  the  former  effect ;  while 
many  chronic  forms  of  the  disease  are  probably  largely  de- 
pendent upon  the  latter.  I  am,  however,  far  from  believing 
that  most  of  the  striking  irregularities  in  the  rate  of  growth  of 
cancers  can  be  accounted  for  by  circulatory  disturbances.  The 
inherent  properties  of  the  neoplastic  cells  themselves  here  play 
the  leading  part. 

The  most  frequent  anatomical  cause  oi  congestmi  and  inflam- 
mation of  cancers  is  obstruction  of  their  venous  circulation, 
which,  as  I  have  previously  mentioned,  so  often  happens  during 
the  process  of  their  growth.  Cancers  are,  however,  less  fre- 
quently subject  to  acute  inflammation  than  might  a  priori  be 
expected.  When  this  does  occur,  not  only  the  neoplasm  itself, 
but  also  its  immediate  surroundings  may  be  affected.  Such 
attacks,  which  are  mostly  of  septic  origin,  often  greatly  accele- 
rate the  progress  of  the  disease.  Subacute  inflammations  are 
commoner  than  the  acute  ones.  Cohnheim  believes  that  inflam- 
matory conditions  of  the  surrounding  tissues  weaken  their 
capacity  for  resistance,  and  so  favour  the  spread  of  the  disease. 
Inflammation  of  cancer  may  terminate  in  resolution,  suppuration, 
or  gangrene.     Suppuration  is  rare,  but  it  undoubtedly  does  occur. 

Habermaas'"'-'  relates  a  curious  case,  in  which  the  breast  was  amputated 
for  a  tumour — accompanied  by  enlarged  axillary  glands — which  was 
believed  to  be  tubercular.  On  examination  of  the  part  after  removal  this 
diagnosis  appeared  to  be  correct,  for  there  was  revealed  a  pus-containing 
cavity,  surrounded  by  caseous  looking  masses.  However,  histologically 
examined,  these  proved  not  to  be  tubercular,  but  cancerous. 

Gross""  mentions  the  case  of  a  woman  whose  breast  he  amputated  for  a 
cancerous  tumour  the  size  of  a  hen's  ^g'g.  On  section  of  the  growth  after 
removal,  he  found  in  it  an  abscess  full  of  greenish  pus. 


Beitraqe  z.  klin.  Cliir.,  1886,  Ikl.  ii.,  .S.  44. 
Am.  Syst.  Gyn.,  vol.  ii. 


INFLAMMATION,    GANGRENE,    ETC.  225 

A  more  frequent  ending  than  suppuration  x?,  gangrene.  This 
is  generally  only  partial  (necrosis),  but  exceptionally  the  whole 
neoplasm  may  fall  into  a  state  of  slough,  as  in  cases  recorded  by 
Nunn,^^^  Broca/^^  and  Warren. ^^^  Ulcerated  cancers  are  more 
prone  to  gangrene  than  others.  Sometimes  the  sphacelus  is 
determined  by  injury  ;  but  usually  there  is  no  obvious  cause. 
Obliteration  of  the  veins  is  its  chief  determining  factor  ;  hence 
it  is  generally  of  the  moist  kind,  but  the  dry  form  is  not  un- 
known. Gangrene  is  always  a  harmful  complication  ;  severe 
local  inflammation  and  pain  attend  it,  together  with  profuse 
foetid  discharge,  pyrexia,  and  much  constitutional  disturbance  ; 
and  the  danger  from  sepsis  is  very  great.  Gangrene  may  be 
followed  by  almost  complete  cicatrisation  ;  but,  as  the  disease  is 
never  entirely  destroyed,  recurrence  is  inevitable — at  any  rate,  I 
cannot  cite  a  single  instance  of  cure  by  gangrene. 

Like  their  physiological  prototypes  of  the  mamma,  sebaceous 
glands  and  epidermis,  the  cells  of  breast  cancers  are  short  lived. 
Hardly  ever  can  one  examine  a  cancerous  tumour  without 
discovering  some  of  its  cells  \x\  fatty  degeneration,  and  this  even- 
tually ends  in  their  complete  disintegration.  Such  conditions 
have  little  or  nothing  to  do  with  circulatory  disturbances  ;  they 
occur  as  regular  stages  in  the  evolution  of  the  disease,  owing  to 
molecular  changes  inherent  to  the  cells  themselves.  To  this 
cause  we  must  attribute  the  tendency  of  mammary  cancers  to 
spontaneous  ulceration,  at  a  certain  stage  of  their  development ; 
which  may  begin,  as  Hunter  pointed  out,  either  superficially  or 
deeply.  In  the  former  circumstance  the  growing  tumour 
becomes  adherent  to  the  overlying  skin,  which  gets  thinned  and 
excoriated  and  eventually  yields,  leaving  the  surface  of  the  neo- 
plasm exposed,  and  this  consequently  ulcerates ;  in  the  latter, 
the  changes  leading  to  ulceration  begin  in  the  substance  of  the 
neoplasm,  and  open  outwards.     Ulceration  once  started  usually 


'"  "  Cancer  of  the  Breast,"  1882,  p.  53. 

"-  "  Traite  des  Tumeurs,"  t.  i. ,  ch.  x. 

113  <<  Surgical  Observations  on  Tumours,"  p.  274. 

15 


226 


THE    MORPHOLOGY    OF    MAMMARY    CANCER. 


tends  to  spread  indefinitely  ;  yet  a  cancerous  neoplasm  is  never 
completely  destroyed  in  this  way,  for  the  disease  progresses 
faster  than  the  ulcerative  process. 

The  typical  ulcer  of  mammary  cancer  presents  as  an  irregu- 
larly rounded,  excavated,  crater-like  cavity,  with  hard,  raised, 
swollen,  craggy  edges,  which  are  usually  everted  ;  and  to  these 
edges  the  surrounding  skin  is  always  adherent  (fig.  42).  Dirty 
yellowish,  sloughy  shreds  cover  its  surface  ;  beneath  which  are 
undulating   projections  of  the    underlying   denuded   neoplasm, 


Fk;.  42. — Ulcerated  Cancer  of  the  Breast  (Bryant). 


covered  here  and  there  with  areas  of  ill-formed  granulations. 
The  ulcer  is  obviously  scooped  out  of  the  subjacent  cancerous 
growth,  hence  its  hardness  ;  hence  also  its  intimate  adhesions 
with  adjacent  structures.  From  the  ulcer  there  exudes,  thin 
acrid,  dirty  yellowish  ichor,  which  is  often  blood  stained  ;  it 
has  a  peculiar  penetrating  and  most  disagreeable,  foetid  odour. 
Its  contact  with  the  surrounding  skin  often  causes  inflammation 
and  even  excoriation.  In  these  respects  it  differs  from  true  pus  ; 
it  differs  also  in  its  composition,  which,  among  other  things, 
comprises  necrotic  shreds  of  the  growth,  degenerated  neoplastic 
cells,  leucocytes,  altered  blood  corpuscles,  oil  globules,  granular 
dtfbris  and  various  micro-organism.s. 


INFLAMMATION,    GANGRENE,     ETC.  2  2/ 

Cancerous  ulcers  of  long  standing  often  present  quite  a 
different  aspect  to  the  foregoing  :  they  are  shallow,  with  slightly 
raised  and  sinuous  edges,  the  base  comparatively  smooth,  and 
covered  with  small  granulations,  which  in  places  have  a  florid 
and  almost  healthy  appearance.  A  thin  parchment-like  layer 
of  indurated  cancerous  tissue  underlies  the  whole  affected  area, 
and  binds  it  to  the  subjacent  structures.  Such  ulcers  not  unfre- 
quently  cicatrise  more  or  less  extensively,  especially  at  those 
spots  where  the  progress  of  ulceration  has  destroyed  the  sub- 
jacent morbid  growth;  and  they  may  even  remain  for  long 
periods  in  a  non-progressive,  quiescent  state.  The  conditions 
underlying  these  favourable  changes  are  closely  allied  to  those 
that  determine  the  so-called  atrophic  form  of  the  disease. 

Cancerous  ulcers  of  the  breast  are  liable  to  bleed  ;  but  they 
seldom  bleed  freely,  and  the  haemorrhage  is  easily  arrested,  if  it 
does  not  cease  spontaneously  as  is  usually  the  case.  The  only 
really  dangerous  kind  of  haemorrhage  to  which  they  are  liable  is 
that  due  to  perforation  of  small  arteries,  and  this  is,  fortunately, 
the  rarest  of  all. 

Various  forms  of  abnormal  fat  formation  in  cancerous 
tumours  arise  in  connection  with  circulatory  disturbances, 
influencing  the  metabolism  of  their  cells.  Thus,  parts  where 
growth  is  exceedingly  active  sometimes  exhibit  a  kind  of  local 
embonpoint ;  that  is  to  say,  fat  globules  are  separated  and 
deposited,  which  would  have  been  oxidised  and  removed,  but 
for  the  local  supply  of  nutritive  materials  being  in  excess  of 
metabolism. 

Localised  fatty  degenerations,  due  to  deficient  blood  supply 
through  venous  congestion,  inflammation,  thrombosis,  arteritis, 
&c.,  are  of  frequent  occurrence.  When  the  arteries  are  seriously 
interfered  with,  considerable  areas  of  the  neoplasm  may  be 
affected  in  this  way.  In  such  cases,  not  only  the  cells,  but  the 
stroma  also  may  degenerate — as  in  the  so-called  lipomatous 
cancers. 

In  like  manner  the  areas  of  caseous  softening,  sometimes 
seem  irregularly  scattered  throughout  cancerous  tumours  arise 


228  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

as  in  the  so-called  "  caseating  ca?tcers."^^'^  The  ultimate  fate  of 
such  lesions  is  chiefly  dependent  upon  the  subsequent  cellular 
changes  ;  if  these  go  on  to  complete  disintegration,  the  resulting 
products  may  be  absorbed  and  completely  disappear,  or  they 
may  liquefy  and  form  cysts,  or  caseate  and  eventually  even 
cretify. 

In  connection  with  circulatory  defects,  mention  must  be 
made  of  the  diffuse  overgrowth  of  the  fatty  capsule  of  the 
mamma  {capsular  lipoma),  which  occasionally  accompanies 
cancer  of  this  organ,  when  the  peripheral  circulation  is  inter- 
fered with  in  the  progress  of  the  disease.^^^ 

EccJiymoses  and  hcemorrhages  into  the  substance  of  mammary 
cancers  are  not  very  common.  Blood  thus  effused  may  be  com- 
pletely absorbed  ;  or,  this  being  incomplete,  the  residue  maj- 
cretify  or  originate  a  cyst. 

Cysts  thus  arising  can  generally  be  distinguished  by  their 
yellowish  lining  membrane,  and  straw-coloured  fluid  contents. 
Other  cysts  arise  in  connection  with  mammary  cancers  owing  to 
dilatation  of  terminal  gland  structures,  through  proliferation  of 
their  epithelia  with  subsequent  mucoid  or  fatty  degeneration. 
Simple  involution  cysts  may  also  co-exist  with  acinous  cancer. 
Intra-cystic  papillary  growths  are  hardly  ever  met  with  in  this 
variety  of  the  disease.  The  so-called  "  hremorrhagic  cancers  "^^*' 
are  not  of  the  acinous  variety  ;  they  are  either  tubular  duct 
cancers  or  villous  papillomas  :  the  pseud-alveolar  appearances 
often  noticeable  on  histological  examination,  when  closely 
studied,  are  very  different  from  the  alveoli  of  acinous  cancer. 

Calcification  and  ossification  of  the  stroma,  as  previously 
mentioned,  is  of  very  rare  occurrence. 

The  changes  produced  in  mammary  cancers  by  the  r^/ZrJ/V/, 
myxomatosis  and  atropine  metamorphoses,  constitute  special 
varieties  of  the  disease  {q.  v.,  ch.  xi.). 

"^  For  cases  by  Masterman,  vide  Bart.'s  Hasp.  Rep.,  vol.  xxvii.,  1891. 
"'*  See  Virchow's  Palh.  ties  Tut/iciiis,  t.  i.,  p.  372,  with  figure. 
""  For  some  cases   liy   Masterir.an,   vide  BartJ's  Hasp.   Rep.,  vol.    xxvii.,   1891, 
p.  193- 


INFLAMMATION,    GANGRENE,    ETC.  2  29 

I  have  before  mentioned,  that  the  characteristic  feature  of 
cancer  is  its  tendency  to  persist  indefinitely,  and  to  increase 
continuously.  Yet  indications  are  not  wanting  of  occasional 
spontaneous  arrest  of  the  disease,  and  even  of  its  retrogression  ; 
but  I  cannot  cite  a  single  instance  of  its  complete  spontaneous 
cure.  Nevertheless,  in  face  of  the  following  facts,  I  think  it 
would  be  rash  altogether  to  deny  the  possibility  of  such  a 
fortunate  occurrence.  The  extreme  chronicity  of  certain  cases 
of  acinous  mammary  cancer  shows,  that  the  increase  of  the 
disease  may  sometimes  be  so  exceedingly  slow,  as  hardly  to  be 
appreciable.  Instances  of  this  kind  are  of  more  frequent  occur- 
rence than  is  generally  believed  ;  and,  what  is  still  less  appre- 
ciated is,  that  the  great  majority  of  such  cases  are  morphologically 
indistinguishable  from  ordinary  acinous  cancer  (scirrhus),  being 
neither  of  the  atrophic  nor  of  the  colloid  variety,  although  both 
atrophic  and  colloid  cancers  exhibit  in  a  high  degree  the 
tendency  to  chronicity.^^'' 

Several  examples  have  also  been  recorded  of  actively  pro- 
gressive scirrhus  cancers — even  when  ulcerated — having  subse- 
quently subsided  into  quiescent,  non-progressive  states,  with 
eventual  great  diminution  in  size.  Nutritive  failure  leading  to 
degenerative  changes  in  the  constituent  cells  of  the  neoplasm, 
and  so  eventually  to  their  complete  destruction  by  disintegration, 
seems  to  be  a  factor  in  many  cases  ;  but  it  is  probably  seldom 
the  chief  one.  The  following  are  some  of  the  best  examples  of 
this  healing  tendency  known  to  me  : — 

Case  i."® — A  lady,  the  whole  of  whose  right  mammary  region  was  occu- 
pied by  a  thin,  smooth,  parchment-Hke,  glossy  scar,  which  extended  back- 
wards beyond  the  mid-axillary  line ;  its  edge  was  slightly  elevated,  hard  and 
sinuous,  like  that  of  rodent  ulcer.  Near  this  large  scar-like  area,  were 
several  small,  isolated  patches  of  similar  appearance.  The  left  mammary 
region  was  affected  in  the  same  way.  Near  the  anterior  border  of  the  left 
axilla  was  a  subcutaneous  nodule,  the  size  of  a  hazel-nut.  This  was  the 
only  situation  in  which  the  growth  had  any  thickness.  Nowhere  was  there 
even  a  trace  of  ulceration.     There  were  a  few  hard  glands  in  each  axilla, 

"'  For  cases  viJe  Ch.  xi.,  §  2. 
"*  W\x\.z\m\%on\  Archives  of  Surgery,  vol.  ii. ,  No.  b>,  April,  1S91,  p.  354. 


230  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

none  of  them  larger  than  horse-beans.  The  disease  began  as  a  hard  tumour 
in  the  right  breast  thirteen  years  ago,  and  it  only  subsequently  invaded 
the  left  breast.  Never  at  any  stage  had  it  ulcerated.  She  consulted  Mr. 
Hutchinson  on  account  of  pulmonary  complication  of  recent  development, 
which  was  thought  to  be  due  to  fluid  in  the  right  pleura.  After  the  chest 
had  been  tapped  several  times  without  any  fluid  being  discovered,  it  be- 
came evident  that  the  dulness  was  due  to  intra-thoracic  solid  growth.  The 
patient  died  about  two  months  later  from  this  cause  ;  but  there  was  no 
necropsy. 

Case  2."''—  A  healthy-looking,  childless,  married  woman,  aged  33,  with  an 
ulcerated  cancerous  tumour  of  the  right  breast,  of  stony  hardness,  and 
firmly  fixed  to  the  pectoral  muscle.  The  tumour  was  first  noticed  six  years 
ago  ;  and  ulceration  began  four  years  ago.  The  ulcer  was  the  size  of  the 
palm  of  the  hand,  its  edges  nodular  and  crumbly.  The  axillary  glands  en- 
larged and  hard.  Operative  interference  was  declined.  Fifteen  months 
later  the  tumour  was  obviously  smaller  and  harder  ;  and  several  pieces — 
the  size  of  nuts— had  shed  from  its  edge.  Six  months  later  it  had  still 
further  diminished,  and  much  of  the  original  tumour  had  crumbled  away. 
Some  discrete  cancerous  tubercles  now  appeared  in  the  adjacent  skin  over 
the  sternum.  In  the  course  of  the  next  year  the  tumour  continued  to  con- 
tract, and  to  throw  ofi"  pieces.  The  cutaneous  tubercles  notably  diminished, 
and  the  axillary  glands  got  smaller  and  harder.  Two  years  later  the  ulcer 
had  almost  completely  cicatrised — a  puckered  linear  scar  was  all  that  re- 
mained, in  which  were  a  few  small  hard  nodules.  The  tubercles  in  the 
adjacent  skin  had  completely  disappeared.  A  year  later  all  that  remained 
of  the  original  disease  was  a  single  nodule,  the  size  of  a  hazel-nut,  in  the 
scar.  The  axillary  glands  were  hardly  perceptible.  The  patient's  general 
health  was  unimpaired.  One  and  a  half  years  later  she  again  came  under 
observation  ;  during  this  interval  several  fresh  tubercles  had  appeared  in 
the  skin  near  the  cicatrix,  and  had  subsequently  disappeared,  so  that  only 
two  small  ones  now  remained.  The  patient  considered  herself  quite  well. 
She  died  five  and  a  half  years  later  of  some  pulmonary  complications,  with- 
out any  obvious  increase  of  the  local  disease  having  taken  place.  Alto- 
gether the  disease  had  lasted  for  nearly  nineteen  years. 

The  two  following  somewhat  similar  cases,  by  Broca,^-"  are 

also  of  much  interest. 

Case  3. — A  woman,  aged  69,  who  died  in  hospital  with  secondary  can- 
cer of  the  liver.  She  was  admitted  with  extensive  chronic  ulceration  of 
the  mammary  region,  which  had  supervened  on  hard  cancer  of  the  breast 
of  many  years'  duration.  The  ulcer  was  shallow;  its  edges  but  slightly 
raised,  and  it  had  commenced  to  cicatrise  in  several  places.  On  micros- 
copical examination  of  the  part  after  death  it  was  found  that  the  whole  of 
the  cancerous  growth  had  been  destroyed  by  ulceration,  except  a  single 
nodule — the  size  of  a  hazel-nut — near  the  centre  of  the  ulcer. 

"»  Bryant,  T.,   "Diseases  of  the  Breast,"  1887,  p.  142- 
'-'"  Traill-  des  J'utiieurs,  t.  i.,  1 866,  p.  240. 


INFLAMMATION,    GANCIRENE,    ETC.  23 1 

Case  4. — A  lady,  who  when  first  seen  had  an  irregular  scar  in  the  mam- 
mary region,  in  connection  with  which  there  was  a  small  hard  cancerous 
nodule  of  some  months'  growth.  She  said  that  fifteen  years  previously  she 
rirst  noticed  a  tumour  in  her  breast,  which  subsequently  ulcerated,  and  after 
a  time  healed  up  without  any  operation  ever  having  been  done.  Some  time 
afterwards,  however,  a  fresh  growth  appeared  in  the  cicatrix,  which  later  on 
ulcerated,  but  again  the  ulcer  healed  spontaneously,  after  which  the  present 
recurrence  set  in.  She  refused  operative  treatment.  The  disease  subse- 
quently progressed  so  rapidly,  that  she  died  of  it  a  few  months  later. 

Some  instances  of  retrogression  of  the  local  disease,  as  in  the 
two  following  cases,  coincide  with  its  outbreak  in  remote  parts 
of  the  body.  These  seem  greatly  to  have  impressed  the  old  sur- 
geons, who  erroneously  regarded  them  as  true  metastases,  which 
term  they  henceforth  applied  to  all  systemic  disseminations. 

Case  5.'^' — A  woman,  aged  40,  with  an  infiltrating  cancerous  tumour  of 
the  left  breast,  the  size  of  an  apple,  who  refused  operation.  One  year  later 
she  again  came  under  treatment  with  paraplegia  due  to  dissemination  of  the 
disease  in  the  vertebree.  The  former  tumour  with  its  surrounding  infiltra- 
tion had  completely  disappeared  ;  in  its  place  nothing  remained  but  a  flat, 
indurated  superficial  scar,  which  was  slightly  excoriated. 

Case  6.'-- — A  very  cachectic  woman,  with  non-ulcerated  hard  cancer  of 
the  breast  of  two  years'  duration,  was  seized  with  violent  cephalalgia,  fol- 
lowed by  apoplectic  symptoms  with  hemiplegia.  At  about  the  time  of  this 
attack  the  mammary  tumour  notably  diminished  ;  and  when  she  died,  ten 
weeks  later,  it  had  almost  completely  disappeared.  The  necropsy  revealed 
a  cancerous  tumour,  the  size  of  a  nut,  in  the  brain. 

In  the  next  case  I  have  to  relate,  subsidence  of  the  can- 
cerous disease  coincided  with  the  active  progress  of  pulmonary 
tubercle. 

Case  ']}■-'■ — The  patient  was  only  25  years  old,  yet  she  had  a  large 
hard  cancerous  tumour  of  the  breast.  The  disease  had  progressed  very 
rapidly,  its  total  duration  being  only  three  months.  The  overlying  skin  and 
nipple  were  invaded.  The  axillary  glands  were  enlarged  and  hard.  The 
breast  was  amputated,  when  the  swelling  of  the  axillary  glands  subsided. 
Six  months  after  this  operation  there  was  recurrence  in  the  mammary 
region  and  in  the  axilla.  In  the  former  situation  the  disease  made  rapid 
progress  ;  numerous  tubercles  formed  in  its  vicinity,  which  coalesced,  and 
eventually  ulcerated.  Thus  it  progressed  for  a  year,  when  the  ulcer  began 
to  cicatrise,  and  in  the  course  of  six  months  it  had  almost  completely  healed. 


'2'  Billroth,  Th.,  Deutsche.  Chir.,  Lief.  41,  1880,  S.  106. 

'--  Walshe,  W.  H. ,  "  The  Nature  and  Treatment  of  Cancer,"  1846,  p.  no. 

'^  Paget,  J.,  "Lectures  on  Surg.  Pathology,"  vol.  ii.,  1853,  page  337. 


232  THE    MORPHOLOGY    OF    MAMMARY    CANCER. 

The  axillary  disease  also  subsided,  one  hard  lump  alone  remaining  of  what 
had  been  a  larg^e  cluster  of  hard  glands.  Meanwhile,  however,  the  patient 
had  emaciated  and  lost  strength,  and  she  died  about  two  years  after  the 
operation,  and  six  months  after  the  cancer  had  so  nearly  healed,  of  tuber- 
culosis of  both  lungs.  On  careful  examination  of  the  mammary  region  after 
death,  a  thin,  flattened,  nodular  p/aqiw  of  extremely  hard  and  dense  cancer, 
was  found  beneath  the  old  scar,  binding  it  to  the  pectoral  muscle.  In  the 
axilla  was  a  suigle  hard  cancerous  gland  ;  and  the  liver  contained  several 
equally  hard  growths. 

Siggi^^  and  others  have  met  with  similar  cases. 

Lastly,  it  remains  for  me  to  mention  that  in  the  penultimate 
stage  of  cancerous  cachexia  and  other  exhaustive  illnesses, ^-'^ 
cancerous  growths  often  become  stationary,  and  even  appear 
to  wither  and  dry  up,  shortly  before  death. 

Probably  most  of  the  alleged  curative  results  of  erysipelas 
inoculations  for  cancer  should  be  included  under  this  headincr.i^e 


'■-'   Corresp.-blaii.  f.  sch.  Aeriz,  15  av.,  1891. 

'-'  For  a  case  of  retrogression  of  mammary  cancer,  after  an  operation  fur  goitre, 
followed  by  much  suppuration,  vide  Perrion.  Rev.  med.  de  la  Suisse  Ko/naude,  xi 
mars   p.    195. 

'■■^  As  in  Janicke  and  Ncisscr's  case,  Ceni,  /.  Chir.,  1884,  5:c. 


233 


CHAPTER  X. 
The  General  Pathology  of  Mammary  Cancer. 


8     I. The  Influence  of  Sex. 

The  influence  of  sex  in  the  development  of  cancer  is 
very  marked.  Not  being  aware  of  any  comprehensive  statistics 
on  this  subject  embracing  a  sufficiently  large  number  of  cases 
to  be  thoroughly  reliable,  I  have  made  an  analysis  of  14,480 
primary  neoplasms  of  all  kinds,  consecutively  under  treatment 
in  the  medical  and  surgical  wards  of  four  large  metro- 
politan hospitals  during  the  sixteen  to  twenty  years  preceding 
1888.^  This  list  comprises  7,878  consecutive  cases  of  cancer — 
2,861  males  and  5,017  females,  or  the  proportion  is  i  male  to  17 
females.  The  mortality  returns  of  the  Registrar-General  for 
the  twenty-five  years  1872-48,  which  include  all  kinds  of 
malignant  disease,  give  a  proportion  of  i  male  to  2-29  females. 
One  male  died  of  cancer  to  every  100  male  deaths  from  all 
causes,  and  one  female  died  of  this  disease  to  every  41  female 
deaths.^  Of  late  this  distinction  has  diminished,  owing  to  the 
increasing  cancer  mortality  falling  unduly  on  males.  For 
instance,  during  the  period  1881-84,  the  death  rates  were — 
males,  3*79;  females,  6'92 ;  ratio,  1  to  i*8.  For  the  year  1890 
they  were — males,  5'I2;  females,  8"30 ;   ratio,  i    to   i'6.     Thus 

'  "  The  Initial  Seats  of  Neoplasms  and  their  Relative  Frequency,"  Annals  of 
Surgery,  October,  1891. 

'Total  mortality,  10,512,146;  males,  5,419,865;  females,  5,082,281.  Total 
cancer  mortality,  177,300;  males,  53,867;  females,  123,433.  Thus  the  cancer 
mortality  =  I  in  59  of  all  deaths. 


2  34         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

the  female  liability  to  cancer  now  is  considerably  less  than  twice 
that  of  males.^  The  relative  liability  of  females  to  non-malignant 
neoplasms  and  cysts  is  even  greater  than  it  is  to  cancer.  This 
arises  from  the  great  frequency  with  which  in  women  the  repro- 
ductive organs — uterus,  mamms,  and  ovaries  are  attacked, 
the  corresponding  male  organs  seldom  being  affected.  The 
localisation  of  neoplasms  is,  indeed,  singularly  influenced  by 
sex,  and  this  is  especially  true  of  cancerous  neoplasms. 

To  illustrate  this  I  have  compiled  the  following  tables  based 
on  the  analysis  of  7,297  cases  of  primary  cancer — 2,669  males 
and  4,628  females  —  consecutively  under  treatment  in  the 
medical  and  surgical  wards  of  four  large  metropolitan  hospitals. 


Females  (4,628  Cases). 


Males  (2,669  Cases) 


Per  cent. 

Per  cent. 

Breast          

40-3 

Tongue  and  mouth 

26-3 

Uterus         

34'o 

Skin   ... 

i4'3 

Rectum       

4-3 

Lip      

122 

Skin... 

4-1 

Stomach       

8-3 

External  genitalia... 

3-4 

Rectum 

7-5 

Stomach      

2-8 

External  genitalia   ... 

6-8 

Liver 

2-5 

OEsophagus  ... 

5-3 

Tongue  and  mouth 

2-i8 

Liver  ... 

4-4 

Intestines 

106 

Intestines      

1-9 

(Esophagus 

070 

Breast            

0-6 

Lip 

006 

Prostate         

0-3 

All  other  localities... 

4-60 

All  other  localities  ... 

I2'I 

lOO'OO 

lOO'O 

This  shows  that  40'3  per  cent,  of  all  cancers  in  females  are 
of  the  mammae,  and  34  per  cent,  of  the  uterus  ;  whereas  in 
males  only  0"6  per  cent,  of  all  their  cancers  attack  the  mammse, 
and  only  about  0*3  per  cent,  the  prostate.  On  the  other  hand, 
26"3  per  cent,  of  all  cancers  in  males  affect  the  tongue  and 
mouth,  I4"3  per  cent,  the  skin,  and  I2'2  per  cent,  the  lower  lip; 


^  I  am  indebted  to  Dr.  Macdonald,  of  Dunedin,  for  calling  my  attention  to  the 
remarkable  sex  distinction  of  cancer  in  New  Zealand.  During  the  years  1879-89, 
1,772  deaths  from  cancer  took  place  there,  and  of  these  893  were  males  and  only 
879  females.  Of  233  cancer  patients  under  treatment  at  the  Dunedin  Hospital 
during  the  same  period,  140  were  males,  and  only  93  females.  This  is  the  only 
country  in  the  world  known  to  me  in  which  cancer  i>  more  prevalent  among  males 
than  among  females. 


THE    INFLUENCE    OF    SEX.  235 

whereas  in  females  only  2"  18  per  cent,  of  all  their  cancers 
attack  the  tongue  and  mouth,  4*1  per  cent,  the  skin,  and  0"o6 
the  lower  lip. 

The  same  subject,  from  another  standpoint,  is  further  illus- 
trated by  the  following  table  : — 

MALES.  FEMALES.  TOTAL. 

Breast      16  1,863  1,879 

Uterus  and  Prostate     ...  7  1,571  1,578 

Tongue  and  Mouth      ...  703  loi  804 

Skin         381  190  571 

Rectum 199  202  401 

Stomach...         ...         ...  222  130  352 

External  Genitalia        ...  182  158  340 

Lip  (Lower)        326  3  329 

Liver       115  113  228 

(Esophagus        144  ,  35  179 

Intestines            49  49  98 

Superior  Maxilla           ...  42  28  70 

Bladder 43  16  59 

Testis  and  Ovary          ...  27  27  54 

Larynx 34  4  38 

Anus        17  10  27 

All  other  localities        ...  162  128  290 

Total 2,669  4,628  7,297 

This  shows  that  of  1,879  consecutive  cases  of  mammary 
cancer  in  both  sexes,  only  16  were  of  the  male  breast,  or  i  in 
117.  According  to  Paget,  98  cases  out  of  every  100  occur  in 
women.  The  like  peculiarity  is  noticeable  with  regard  to 
uterine  cancer,  for  it  is  met  with  224  times  oftener  than  pros- 
tatic cancer.  In  almost  all  other  localities — except  the  sexual 
glands,  liver,  rectum,  and  intestines,  where  both  sexes  are 
equally  liable — the  male  proclivity  to  cancer  greatly  exceeds 
that  of  the  female.  In  the  lower  lip  it  is  108  times  as  great,  in 
the  tongue  and  mouth  7  times,  in  the  oesophagus  17  times,  and 
in  the  external  genitals  i'2  times. 

Curiously  enough  sarcomas,  which  manifest  no  very  marked 
tendency  to  attack  the  female  reproductive  organs,  are  nearly 
equally  distributed  between  the  sexes. 

From  the  foregoing  facts  we  may  draw  this  conclusion  :  that 


236 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


the  greater  liability  of  females  to  cancer  is  not  the  outcome  of 
any  general  constitutional  condition  correlated  with  sex,  but 
that  it  is  due  to  biological  peculiarities  inherent  to  the  repro- 
ductive organs  themselves.  In  the  breast,  for  instance,  most 
neoplasms  originate  in  the  immediate  vicinity  of  the  acini  and 
small  ducts ;  whereas  it  is  very  rare  for  such  growths  to  arise 
from  the  skin  of  the  mammary  region,  the  areola,  the  nipple,  the 
large  ducts  or  the  para--))iaimnary  fibro-fatty  tissue.  That  is  to 
say,  mammary  neoplasms  are  most  prone  to  arise  in  the  sites  of 
greatest  post-embryonic  developmental  activity,  where  cells  still 
capable  of  growth  and  development  most  abound.  The  like  is 
true  of  the  other  organs. 

Since  the  foregoing  was  written,  1  have  had  the  opportunity 
of  studying  the  localisation  and  sex  distribution  of  the  disease, 
as  shown  by  the  chief  mortality  returns.  From  these  I  have 
compiled  the  subjoined  tables,  showing  the  localities  affected 
per   100  deaths  from  cancer  in  each  sex. 

Thus  treated,  the  English  reports,  which  are  based  on  returns 
for  the  years  1868  and  1888,  yield  the  following  results  : — 


FEl 

VIALES. 

M.\LES. 

Per  cent. 

Per  cent. 

Uterus  (ovaries, 

vagina, 

and 

Stomach        

29-6 

vulva)    ... 

347 

Liver... 

I3"4 

Breast 

21-2 

Rectum         

8-3 

Stomach 

io"9 

Tongue  and  mouth 

7-6 

Liver 

9"5 

Intestines 

5  "3 

Rectum 

4-2 

Face 

47 

Intestines 

37 

Oisophagus  

3*3 

Face 

i'3 

Bladder        

2-6 

Tongue  and  mouth... 

v\ 

Lip 

2-4 

CEsophagus  ... 

vo 

Jaw     ... 

2-3 

Pharynx,  fauces 

tonsils 

&c. 

0-8 

Pharynx,  fauces,  tonsils,  &c 

2-2 

Bladder 

07 

Prostate         

o"3 

Jaw     ... 

0-6 

Breast            

01 

All  other  localities  ... 

10-3 

All  other  localities 

17-9 

1000  1000 

With  this  the  following  table,  based  on  data  derived  from 
the  Irish  reports  for  the  years  1887,  1888,  and  1889,  may  be 
compared  ;  thus  : — 


THE    INFLUENCE    OF    SEX. 


237 


FEMALES. 

Per  cent. 

MALES 

Stomach 

22-4 

Stomach 

Breast 

21-5 

Liver  ... 

Uterus 

14-1 

Lip     ... 

Liver  ... 

8-8 

Face  ... 

Face  ... 

4"2 

Tongue 

Intestines 

■  >■              t  ■■ 

30 

Throat 

Rectum 

27 

Rectum 

Leg    ... 

2-4 

Jaws  ... 

Throat 

1-6 

Neck  ... 

Neck  ... 

1-4 

Leg    ... 

Lip     ... 

ro 

Intestines 

Jaws  ... 

ro 

Hand... 

Eye    ... 

0-8 

Head... 

Hand... 

07 

Eye    ... 

Foot  ... 

07 

Foot  ... 

Tongue 

0-6 

Breast 

Head... 

0-5 

All  other  localities  ... 

All  other  localities  ... 

12-5 

Per  cent. 

34'3 

77 
6-4 

6-3 
4-6 
4-6 
3-6 
3  "4 

3"2 
2-9 

0-8 
07 
07 
0-3 
12-5 


Analysis  of  the  Frankfort-on-Main  Cancer  Mortality  Re- 
turns* for  the  thirty  years,  1860-89,  gives  the  following 
results  : — 


Females 


Uterus   ... 

Stomach 

Liver 

Breast    ... 

Intestines 

Ovaries 

Peritoneum,  &c. 

Nervous  system 

OEsophagus 

Vagina  ... 

Bladder 

Kidneys 

Tongue 

All  others 


Per  cent. 
..       27-5 

..     i8-3 

I2'6 

•  11-3 
..       8-8 

•  37 
.       3-6 

\-2 
I'l 

•  0-9 

.  0-8 

.  0-4 

•  o"3 

•  9-5 

lOO'O 


Males 


Per  cent. 

Stomach 

..       29*2 

Liver 

.     i8-6 

Intestines 

.     11-6 

Oesophagus  and  pharynx 

■       6-5 

Bladder,  penis,  &c 

.       4-0 

Peritoneum,  &c. 

•       3"o 

Nervous  system 

.       2-6 

Tongue 

2"0 

Respiratory  system    ... 

2-0 

Kidneys 

2'0 

All  others          

.     i8-5 

Cited  by  King  and  Newsholme,  Proceedings  Roy.  Soc,  vol.   liv.,  No.  327,  p.  239. 


238         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

It  will  be  seen  that  these  mortality  estimates  differ  from  the 
clinical  data  gathered  by  me,  chiefly  in  that  they  show  much 
greater  frequency  of  the  disease  in  the  stomach,  liver,  and 
intestines;  and  its  less  frequency  in  the  female  breast,  skin, 
tongue  and  mouth,  lips,  &c.  The  ponderous  data  from  which 
they  have  been  compiled  are  confessedly  not  altogether  reliable; 
and  it  is  highly  probable  that  the  deaths  attributed  to  cancer  of 
the  stomach,  liver,  and  intestines  have  been  exaggerated  owing 
to  diagnostic  errors.  At  the  same  time  I  must  state,  that  these 
figures  are  in  accord  with  most  continental  estimates  (Salle, 
D'Espine,  Virchow,  &c.),  all  of  which  place  the  stomach  at  the 
head  of  their  lists ;  but  these  are  also  based  on  mortality 
returns. 


§     1 1. The  Influence  of  Age. 

The  first  four  quinquennia  of  life  arc  completely  exempt 
from  mammary  cancer  ;  at  least  I  know  of  no  well  authenticated 
case  that  can  be  cited  as  having  occurred  within  this  period. 
Alleged  examples  of  it  by  Lyford  (at  8  years),  Carmichael 
(at  12),  Cooper  (at  13),  Home  (at  15),  &c.,  have  never  been 
histologically  verified.  Henry's^  is  the  earliest  credible  case 
known  to  me ;  and  in  his  patient  the  disease  was  first  noticed 
at  the  age  of  21.  In  a  case  under  my  own  observation  the 
disease  began  at  24.  Its  occurrence  before  25  is,  however,  a 
great  rarity.  In  the  third  decennium,  mammary  cancers  are 
m.et  with  more  frequently,  but  their  number  is  still  small. 
Subsequently  they  occur  with  increasing  frequency  until  the 
quinquennium,  45  to  50,  when  they  attain  their  maximum. 
After  70  the  disease  is  rare,  and  it  is  very  rare  after  80.  The 
oldest  patient  with  mammary  cancer  seen  by  me  was  84  when 
the  disease  commenced  ;  but  Bryant^  has  met  with  an  instance 
in  which  it  began  at  the  phenomenal  age  of  96.     The  oldest 


Statist.  Mittheil.  iiber  den  Brustkrebs,"  Bieslau,  1879. 
■^  "  Diseases  of  the  Breast,"  1887,  p.  149. 


THE    INFLUENXE    OF    AGE. 


239 


cancer  patient  i  have  ever  heard  of  is  the  lady  attended  by 
Coker"  of  Chicago,  who  died,  aged  106,  of  cancer  of  the  tongue. 
According  to  my  estimate,  the  average  age  of  women  at 
the  onset  of  mammary  cancer  is  48  years  ;  whereas  for  uterine 
cancer  it  is  44  ;  for  cancer  of  the  tongue  and  mouth,  50  ;  and 
for  rectal  cancer,  53  }'ears.  The  foregoing  statement  is  based 
on  the  subjoined  analysis  of  500  consecutive  cases  of  breast 
cancer  ;  and  for  the  sake  of  comparison  I  have  appended 
similar  analyses  of  cases  of  uterine  cancer,  and  of  cancer  of 
the  tongue  and  mouth  in  women — all  of  them  reduced  to  the 
percentage  basis. 

Tongue 

and  Mouth.9 

Per  cent. 

3 
5 
7 
4 
10 

17 

22 

TO 

9 
6 

7 


Age  Periods. 

20  to 

25 

years 

25     „ 

30 

'? 

30    „ 

35 

;> 

35   „ 

40 

)5 

40   „ 

45 

)) 

45   „ 

50 

„ 

50  » 

55 

)) 

55   ,> 

60 

)> 

60  „ 

65 

)) 

65   „ 

70 

)J 

Over 

70 

>J 

Breast. 
Per  cent. 

Uterus.8 
Per  cent. 

0-6 

0'2 

4-0 

7-0 

6-0 

ii-o 

14*0 

20'0 

i6'o 

17-0 

20"0 

i6"o 

15-0 

13*0 

lo-o 

9-0 

9-0 

5-0 

3-2 

ro 

2.2 

0-8 

lOO'O 


Mean  age 
Earliest  age 
Latest  age 


24 
84 


44 

22*25 


50 

24 

77'5 


Statistics  by  Gross,  Bryant,  Winiwarter,  Paget,  and  others 
give  very  similar  results. 

We  learn  from  them  the  absolute  frequency  of  the  disease 
at  the  various  age  periods;  but  they  tell  us  nothing  as  to  the 
relative  tendency  to  it  at  different  ages — i.e.^  of  the  influence 
of  age  in  its  evolution.  In  order  to  ascertain  this  we  must 
compare  these  figures  with  the  total  number  of  females  living 


"  British  Medical  Journal,  March  S,  1887,  "Additional  Report  on  Centennrians." 
**  Calculated  on  500  cases. 
^  Calculated  on  90  cases. 


240 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


at  the  corresponding  age  periods.  Calculations  made  in  this 
way  for  malignant  disease  in  general  show  that  the  relative 
liability  to  it  increases  with  each  successive  decade  until  the 
seventy-fifth  year.  The  following  table  from  the  Registrar- 
General's  Report  for  1884^°  illustrates  this  : 


Males. 

Females 

20  to  25  years     

29 

34 

25    „   35      „        

70 

176 

35    »   45      <,        

270 

849 

45   „   55      „        

...          894 

1,953 

55    >,  65      „        

...      2,002 

3,146 

65   „   75      »        

...      3,305 

4,132 

Over   75      „        

...     3,449 

4,135 

All  ages 

379 

692 

In  reference  to  these  results  Dr.  Ogle  remarks  :  "  In  simplj' 
saying  that  the  liability  to  death  from  cancer  increases  with  age, 
no  more  is  said  than  may  be  stated  with  equal  truth  of  liability  to 
death  generally.  The  question  is,  does  the  annual  liability  to 
death  from  cancer  increase  more  rapidly  than  the  annual  liability 
to  death  of  all  kinds  ?  "  To  answer  this  question  he  has  com- 
piled the  following  table,  showing  the  ratio  of  total  deaths  to 
deaths  from  cancer  during  the  decennium  1871-80,  at  succes- 
sive age  periods  : 

Total  Deaths  to  one  from  Cancer. 


Age  Periods. 

Males. 

Females. 

Persons 

20  to   25  ) 

ears 

...      262 

248 

255 

25   „   35 

,, 

...       131 

49 

71 

35   „   45 

,, 

...         57 

15 

24 

45   „    55 

„ 

...         28 

9 

14 

55   „   65 

„ 

TO 

10 

14 

65   „   75 

„ 

...        27 

17 

21 

75  and  up 

wards 

...         56 

44 

48 

It  will  be  gathered  from  the  foregoing,  that  the  charac- 
teristic feature  of  cancer  mortality  is  not  its  increase  with 
advance  of  years,  but  its  disproportionate  increase  in  the  post- 
meridian periods.     This  table  also  shows  very  well  the  relative 


'"  Showing  the    mean    annual    mortality  of  males    and   females  from  cancer  per 
million  living  at  successive  age  periods. 


THE    INFLUENCE    OF    AGE. 


!4I 


liability  of  the  sexes  at  different  ages.  It  will  be  noticed  that 
the  relative  liability  of  females  increases  until  the  period  45-5 5> 
after  which  it  lessens  at  each  decade  in  a  marked  degree. 

With  regard  to  cancer  of  the  female  breast,  statistics  com- 
piled on  this  basis  by  Paget'^  and  Nunn^^  show  that  the  period 
of  its  greatest  relative,  as  well  as  absolute  frequency,  is  between 
the  fortieth  and  fiftieth  years.  Nunn's  table,  which  was  com- 
piled for  him  by  an  actuary,  is  as  follows  :  — 

Age  Periods.  Per  cent. 

25  to  3oyears...         ...         ...         '831 

3'933 

8783 

12-311 

1 8  "006 

i6'i6i 

8-368 

9*696 

9-181 

4-983 

3'923 

3-824 


30  ., 

35 

35  „ 

40 

40  „ 

45 

45  ,, 

50 

50  „ 

55 

55  ,, 

60 

60  „ 

65 

65  „ 

70 

lo   „ 

75 

75  » 

80 

80  „ 

8; 

This  shows  that  the  relative  liability  of  females  to  mammary 
cancer  lessens  progressively  in  a  marked  degree  at  each  age 
period  after  55. 

Considerations  of  this  kind  induced  me  to  investigate  the 
mortality  from  cancer  of  centenarians  and  aged  persons  of  80 
years  upwards.  The  information  thus  obtained  shows  that 
these  aged  persons  are  relatively  much  less  prone  to  the  disease 
than  their  juniors.  Cancer  seldom  originates  in  extreme  old 
age.  Of  797  centenarians  of  whom  the  causes  of  death  are 
tabulated  in  the  Registrar-General's  Reports  for  the  ten  years 
1876-85,  and  for  the  year  1S73,  only  5  died  of  cancer,  or  i  in 
159.  Of  208  males,  2  died  of  cancer,  or  i  in  104;  and  of  5S9 
females,  3  died  of  it,  or  i  in  196. 


"  "  Lect.  on  Surg.  Path.,"  vol.  ii.,  185 j,  p.  326. 
'-■  "  Cancer  of  the  Breast,"  1882,  p.  161. 


16 


242         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

Humphry's  report^^  on  the  maladies  of  old  people  is  of 
similar  import.  Among  202  persons — males  92,  females  1 10 — 
90  years  of  age  and  upwards,  there  was  not  a  single  instance  of 


L— Diagram  showing   the  Mortality   from   Cancer  at  Different  Ages 

IN  Each  Sex.'* 


Ages  at  Death. 

2(^25        TS-X        3543       43^.5        S5-63        6573        rSS5     Oye/83 

MofDeaib 
3.000 

2.rJ0 

2.300 
2.230 
2.000 

j.rdo 

J.^OO 

1  230 

2  000 
750 
300 

250 

Maia    J 

0 
Females 

^ 

\ 

'^ 

N 

y 

\ 

J 

\ 

\  \ 

c 

\  \ 

\  \ 
\ 

\ 

i 
t 

L     \ 

/ 

,j 

: 

••\ 

/......^ 

*N 

1 

___      __: 

T/ieemr/-  W 
fiffu/vs  a/rf , 

47      135       4r3        1220     Jm       im       33J         <?i'li,28i 
39       3.9r     1429      2669     29?:?      2347      961         97) 

malignant  disease  ;  and  of  622  persons — males  340,  females  282, 
between  80  and  90  years  old,  there  were  only  14  instances  of  it. 


'^  Brii.  Med.  Journal,  July  30,  1887. 

'^  The  figures  on  which  this  diagram  is  based  are  from  the  Registrar-General's 
Report  for  the  year  1888 


THE    INFLUENCE    OF    AGE.  243 

Thus  of  these  824  aged  persons,  malignant  disease  was  met  with 
only  in  17  per  cent,  or  in  the  ratio  of  i  to  58'8.  Of  432  males 
7  were  affected,  or  i  in  617;  and  of  392  females  7,  or  i  in  56. 
Of  the  males,  the  lip  was  the  seat  of  the  disease  in  3  cases ;  the 
penis,  ear,  finger,  and  shoulder  each  in  i  case.  Of  the  females, 
in  5  the  breast  was  affected,  and  in  2  the  face. 

These  facts  clearly  show  that  cancer  is  not  a  senile  disease, 
and  that  senility  per  se  plays  no  essential  part  in  its  develop- 
ment. The  contrary  belief  is  a  mere  myth,  that  by  dint  of  con- 
tinual repetition  has  gained  wide-spread  credence,  without  there 
being  a  particle  of  truth  in  it. 

In  order  to  show  plainly  the  differential  influence  of  sex  at 
the  various  age  periods,  I  have  constructed  the  two  following 
diagrams. 

The  first  of  these  (No.  i.)  exhibits  the  absolute  mortality 
from  all  kinds  of  malignant  disease  at  different  ages,  for  the 
year  1888.  From  this  it  is  obvious  that  at  the  period,  20  to  25 
years,  the  mortality  is  nearly  equal  in  both  sexes.  After  this  the 
female  mortality  increases  much  more  rapidly  than  does  the 
male;  but  both  reach  their  maximum  at  the  period  55  to  65, 
and  then  both  decline  rapidly.  Further,  it  will  be  seen  that  the 
female  mortality  greatly  exceeds  the  male  mortality  at  all  age 
periods  when  the  disease  is  most  prevalent,  i.e.,  between  the  end 
of  the  thirty-fifth  and  seventy-fifth  years,  and  the  difference  is 
greatest  at  the  period  of  maximum  prevalency  between  55  and 
65  years.  In  other  respects  the  similarity  in  the  general  out- 
lines of  the  tracings  for  each  sex  is  very  noteworthy. 

The  second  diagram  shows  the  absolute  frequency  with 
which  mammary  cancer  originates  at  different  ages  in  each 
sex.  The  striking  feature  about  the  diagram  is  the  great  simi- 
larity of  the  age  tracings  in  the  two  sexes,  both  of  which  attain 
their  maximum  at  the  period  45-50  years.  Another  note- 
worthy feature  is  the  large  number  of  male  cases  that  originate 
after  70.  This  it  is  that  causes  the  average  age  at  onset  of 
mammary  cancer  in  males  (50  years)  to  exceed  that  in  females 
(48  years).      The  difference   in   the   age   tracings    of  the   two 


244         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

diagrams  should  also  be  noticed,  showing  as  it  does,  that  mam- 
mary cancers  are  most  prevalent  at  an  earlier  age  than  malig- 
nant disease  in  general. 

It  seems  only  natural  to  seek  an  explanation  of  the  great 
frequency  of  cancer  of  the  female  breast  in  the  changes  normally 
incidental  to  the  correlated  pelvic  reproductive   organs  at  this 

n. — Diagram   showing  the  Frequency  of   Mammary   Cancer  at 
Different  Ages  in  Each  Sex.''' 


Percentage 
Coupes 

23  fittrce/ic 

20     .     , 

1^      .     . 
JO     .     . 

^      .     . 

Males 

Proportion  or  Cases  of  Mammary  Cancer  at  diffcrent  Age  Periods. 
K^iy    2SJO    3033    3d40    4043    4330    3033    33-60    6063     63-70  OrttW 

i 

> 

/, 

/ 

\; 

1,^ 

\ 

} 
i 

/ 

p»*<^ 

V 

< 

!l 

Thepercenlagefi' 

n        2         9         12         11         17        13-       12         7           J         10 
■6        4           6         14-         16         iO        IJ         10          S         J  2       2  2 

period.     In  this  connection   I    have  ascertained   the   following 

facts  : — 

Of  eighty-seven   females  with  mammary  cancer  the  disease 

was  first  noticed  : 

Before  the  cessation  of  menstruation  in  35 

At  about  the  time  of  the  menopause   „  10 

After  the  cessation  of  menstruation     „  42 


''■•  Rased  on  the  author's  analysis  of  500  cases  of  cancer  of  the  female  breast  and 
90  of  the  male  breast. 


THE    INFLUENCE    OF    AGE. 


245 


The  only  catamenial  abnormalities  noticed  in  these  patients 
were,  profuseness  in  six,  irregularity  and  scantiness  in  four. 
Sixty-two  per  cent,  of  the  patients  investigated  by  Gross  were 
menstruating  at  the  onset  of  the  disease,  but  in  only  8;45  per  cent, 
of  these  was  there  any  catamenial  irregularity.  The  average  age 
in  eighty  breast  cancer  patients,  at  which  the  catamenial  func- 
tion was  first  established,  I  have  found  to  be  14-5  years  ;  that  for 
English  women  in  general  being  usually  computed  at  15  years. 
The  average  age  at  the  cessation  of  menstruation  in  forty-three 
breast  cancer  patients  under  my  observation  was  46*3  years — 
over  a  year  later  than  the  period  usually  assigned  as  the  date  of 
the  normal  climacteric.  The  following  table,  from  Paget,^^ 
shows  the  ages  at  which  menstruation  ceased  in  400  women, 
and  the  ages  at  which  cancer  of  the  breast  was  first  detected  in 
an  equal  number  : — 


Ce 

ssation 

of 

Ages. 

Me 

nstruation. 

Onset  of  Cancer. 

Below  35 

9 

36 

35  to  40  

51 

62 

40    „  45  

140 

78 

45    »   50  

159 

lOI 

Above  50 

41 

123 

400  400 

These  facts  suffice  to  show  that  the  development  of  cancer  in 
the  female  breast  has  no  causal  connection  with  the  catamenial 
function.  A  glance  at  Diagram  II.,  which  shows  that  the  age 
distribution  of  mammary  cancer  is  nearly  identical  in  both 
sexes,  confirms  this  conclusion. 

To  sum  up  : — We  learn  from  the  foregoing  that  while  the 
forces  of  growth,  development,  and  reproduction  are  in  greatest 
activity — during  the  periods  of  intra-uterine  life,  infancy,  child- 
hood, adolescence,  and  adult  age — the  tendency  to  cancer  is 
exceedingly  small.  In  both  sexes  the  disease  begins  to  be 
frequent  as  soon  as  the  period  of  perfection  has  been  attained, 
i.e.y  after  the  35th  year  ;  during  middle  age  and  the  decline  q{ 


'Lect.  Surg.  Path,,"  vol.  ii.,  1853,  p.  327. 


246         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

life  the  liability  to  it  increases,  until  about  the  55th  year;  after 
which  period  it  becomes  markedly  less  frequent,  and  increasingly 
so  as  age  advances.  The  principles  that  govern  the  age  distri- 
bution of  cancer  in  general,  apply  also  to  its  various  local 
manifestations  in  both  sexes.  That  some  parts  of  the  body — 
such  as  the  uterus  and  mamma — are  attacked  at  an  earlier  age 
than  others,  is  due  to  the  fact  that  the  former  attain  maturity 
earlier  than  the  latter  and  vice  versa.  The  general  rule  for  the 
breast  and  all  organs  is,  that  their  liability  to  cancer  begins  with 
the  decline  of  their  functional  activity,  and  increases  while  this 
is  progressing.  Thus  the  liability  to  cancer  waxes  as  the  de- 
velopmental and  reproductive  activities  wane.  The  antagonism 
between  the  forces  of  genesis,  growth,  development  and  expen- 
diture, is  the  same  in  pathology  as  in  physiology.  It  is  owing 
to  the  varied  interactions  of  forces  thus  called  into  existence, 
that  the  constitution  is  so  different  at  different  periods  of  life ; 
and  that  each  period  has  its  special  morbid  proclivities.  In 
this  we  have  an  illustration  of  the  universal  biological  law 
that  growth  varies  according  to  the  surplus  of  nutrition  over 
expenditure.  So  long  as  the  surplus  exists — that  is  to  say, 
while  nutrition  is  relatively  high — simple  continuous  growth  is 
maintained  ;  but  when  nutrition  is  relatively  low — that  is  to  say, 
when  it  is  nearly  equalled  by  expenditure — new  centres  of 
development  are  apt  to  arise,  and  growth  tends  to  become 
discontijiiioiis.  Changes  of  nutrition  determine  the  transition 
from  the  one  to  the  other  mode  of  growth.-  To  the  operation  of 
such  causes,  as  I  have  elsewhere  maintained,'^  the  origin  of 
cancers  and  other  neoplasms  must  ultimately  be  ascribed. 

§     II  I, Complexion,  Race,  Geographical  Distribution,  and  Topography. 

The  fact  is  well  established  that  when  a  number  of  indi- 
viduals arc  exposed  to  the  influence  of  similar  conditions  of 
life,  all  are  not  identically  affected  ;  and   it  is  evident  that  the 


'  The  Principles  of  Cancer  and  Tumour  Formation,"  London,  1888. 


COMPLEXION,    RACE,    ETC. 


247 


different  effects  thus  induced  depend  upon  inherent  constitu- 
tional differences.  In  human  beings  well-marked  constitutional 
peculiarities  are  correlated  with  complexion  and  race.  I  now 
propose  to  inquire  whether  the  development  of  cancer  is 
influenced  by  these.  To  this  end  I  have  noted  the  complexion 
of  384  cancer  patients  under  my  observation.  In  doing  this  I 
have  relied  chiefly  on  the  colour  of  the  hair  and  eyes,  as  in 
white  people,  these  are  its  most  permanent  and  easily  recognis- 
able factors. 


Males  (128  Cases). 

Dark.       Fair.     Total. 

Tongue  and  mouth    30 


Rectum 

Lower  lip   ... 

Skin 

Tonsil 

Ext.  genitalia 

Rodent  ulcer 

Anus 

(Esophagus 


12 

9 
6 
I 
I 
3 
3 


66 


28 
12 
II 

5 


62      128 


Females  (256  Cases). 

Dark.       Fair.     Total. 


Uterus 
Breast 

Rectum       

Rodent 

Tongue  and  mouth 

Ovary 

Ext.  genitalia 

Vagina 

CEsophagus 

Other  localities     .. 


70 

44 
12 

5 
4 
4 
2 

3 
I 
6 

150 


37  • 

..107 

42  . 

..  86 

5  • 

..  17 

7  • 

..  12 

4  • 

..  8 

2 

..  6 

3  • 

••  5 

I  . 

•  •  4 

2 

■•  3 

5  • 

..  II 

106 

2S6 

The  numerical  results  thus  obtained  show  that  the  majority 
of  cancer  patients  (56  per  cent.)  are  of  the  dark  type;  and  it  is 
to  the  female  sex  that  this  preponderance  is  almost  exclusively 
due.  In  order  to  appreciate  the  significance  of  these  results,  we 
must  first  know  the  proportional  frequency  of  the  dark  and  fair 
types  in  the  general  population.  Dr.  Beddoe^^  has  most  kindly 
furnished  me  with  information  as  to  this.  His  estimate  shows 
that  among  the  London  lower  classes  43  per  cent,  are  of  the 
dark,  and  57  per  cent,  of  the  fair  type.  Hence  it  follows  that 
cancer  is  relatively  much  more  frequent  among  dark  than 
among  fair-complexioned  persons,  the  proportion  being,  accord- 
ing to  my  estimate,  69  per  cent,  of  the  former  to  31  per  cent.  01 
the  latter.  Beddoe's  analysis  nearly  accords  with  this.  He  has 
also  found  that  individuals  of  the  rufus  type  are  relatively  less 
exempt  than  other  fair-complexioned  persons. 


'^  See  also  his  monograph  on  "  The  Races  of  Brilain,"  1885. 


248         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

As  to  the  influence  of  race  in  the  HabiUty  to  cancer,  we  have 
singularly  little  reliable  information. 

The  United  States  statisticians  (Billings,  Barker,  Chisholm) 
are,  however,  agreed  that  the  disease  is  relatively  more  than 
twice  as  frequent  among  the  whites  as  among  the  blacks. 
According  to  Billings^^  of  23,000,000  whites,  6,321  died  of 
cancer;  and  of  9,000,000  blacks,  only  790.  That  is  to  say, 
the  deaths  from  cancer  per  100,000  whites  and  blacks  living, 
were  27'56  and  I2'i7  respectively;  for  whites  the  male  death- 
rate  was  20*5,  and  the  female  death-rate  35*4;  for  blacks  it  was 
for  males  5'8,  and  for  females  19*3.  This  accords  with  the 
almost  unanimous  testimony  of  the  United  States  gynae- 
cologists, who  have  frequently  called  attention  to  the  com- 
parative immunity  of  negresses  from  uterine  and  mammary 
cancer,  although  they  are  very  prone  to  uterine  fibroids.  We 
learn  from  numerous  observers  that  this  comparative  immunity 
of  the  negro  race  from  cancer  is  even  more  noticeable  in  their 
African  homes.  Whether  this  is  due  to  racial  influence  or  to 
savage  ancestry  is  not  easy  to  decide.  Those  who  have 
travelled  among  savage  people  are,  however,  unanimous  in 
asserting  that  cancerous  diseases  are  almost  or  quite  unknown 
among  them.  This  immunity  applies  alike  to  meat-eating  and 
vegetarian  savages.  It  should,  however,  be  borne  in  mind  that 
most  uncivilised  people  get  comparatively  little  animal  food  ; 
or,  at  any  rate,  they  often  have  to  abstain  from  it  for  long 
periods. 

On  the  other  hand,  it  is  certain  that  cancerous  diseases  are 
very  prevalent  in  all  highly  civilised  communities.  Among  the 
whites  in  the  United  States,  Billings  found  that  those  of  Irish 
and  German  extraction  were  the  most  prone  to  cancer.  It  has 
been  asserted  that  the  Jews  are  seldom  affected,  but  in  this, 
Richardson — who  has  had  considerable  experience  among  them 
— does  not  agree  ;  BiUroth's  experience  coincides  with  this  ; 
moreover,  Billings'  report  shows  that  in  the  United  States  their 

'"  "  RepDit  ijii  10th  U.S.  Census,"  vols,  xi.,  xii.,  1880. 


GEOGRAPHICAL     DISTRIBUTION.  249 

death  rate  from  cancer  is  almost  the  same  as  that  of  the  rest  of 
the  white  population. 

Notwithstanding  the  interest  lately  manifested  in  the  geo- 
gyapJiical  distribution  of  cancer,  of  accurate  scientific  information 
there  is  rather  a  dearth.  Statistical  records  have  been  kept 
only  in  Europe,  the  United  States,  and  some  of  our  colonies. 
These  show  the  much  greater  prevalency  of  the  disease  in 
Europe.  According  to  the  "  Report  of  the  loth  United  States 
Census  "  (18S0),  already  referred  to,  the  cancer  mortality  for  the 
whole  country  then  amounted  to  2*22  per  10,000  living,  or  17  per 
1,000  (i  in  59)  of  the  total  deaths. 

For  the  chief  European  countries  the  death  rates  per  10,000 
living  are  : — Sweden  (1886-7),  9-5  ;  Saxony  (1876-85),  6'9  ; 
Netherlands  (1884-88),  6-5;  Italy  (1881-83),  ^'i  ;  England  and 
Wales  (1881-85),  5-47;  Norway  (1862-66),  5-2;  Austria  (1885-87)^ 
48;  Ireland  (1885),  3-9;  Prussia^"  (1876-85),  34.  I  have  been 
unable  to  meet  with  any  recent  statistics  showing  the  mortality 
from  cancer  in  France.  Writing  in  1880,  Lombard^^  says  it 
is  much  in  excess  of  the  English  mortality.  In  Scandinavian 
countries  cancer  is  very  prevalent. 

With  regard  to  the  chief  large  towns  the  cancer  mortality 
of  New  York  (1885)  was  5-2  ;  Philadelphia  (1872-76),  44  ;  of  50 
U.S.  large  cities  (1880),  males  2*8,  females  5'i  ;  and  for  the 
State  of  Massachusetts  (1876-86),  4*6. 

For  some  of  the  chief  European  towns  the  numbers  are  as 
follows: — Edinburgh  (1889),  10*4;  Paris^^  (1886-91),  104;  Bre- 
men (1875-78),  8-1  ;  Hamburg  (1871-83),  j'6\  Aberdeen  (1889) 
7-3  ;  London  (1884),  6-5  ;  Glasgow  (18S9),  6-i  ;  Berlin  (1870-82) 
57;  Bergen  (1886-87),  5-4;  Christiania  (1886-87),  5;  Utrecht 
(1870),  4'9 ;    Brussels    (1874-8),   4*2.     According  to    Lombard, 


^^  The  Prussian  cancer  mortality  for  the  thirteen  years  1875-87  was  \'2\  per  100 
deaths;  the  sex  ratio  147  females  to  100  males.  The  tubercle  mortality  was  I2'4 
per  100  deaths.  Vierteljahres  f.  gericht.  Med.  tind  csff.  SaniL,  3rd.  ser. ,  I.,  314. 
Ap.  1891. 

-'  Trait e  de  Cliinatologie  Med.,  t.  iv.,  p.  520. 

--  According  to  Bertillon  the  Paris  cancer  mortality  for  1889  was  4'I5  per  100  of 
the  total  deaths. 


250        GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

cancer  is  more  prevalent  in  Geneva  than  in  any  other  European 
town.  Of  German  towns,  Frankfort^^  and  Breslau  furnish  the 
most  cases.  The  St.  Petersburg  cancer  mortality  is  less  than 
that  of  Berlin. 

The  disease  is  said  by  Panum  to  be  unknown  in  the  Faroe 
Islands,  and  to  be  very  rare  in  Iceland,  Greenland,  Turkey  and 
Greece — these  results  need  confirming.  Eventually  it  will  pro- 
bably be  found  that  no  place  is  really  exempt. 

Continental  statistics  indicate  much  greater  frequency  of 
the  disease  in  the  stomach,  intestines  and  liver,  than  British 
ones.  Chimney  sweep's  cancer,  rare  in  England,  is  hardly  ever 
met  with  elsewhere. 

Of  Asiatic  countries  it  is  generally  agreed  that  cancer  is 
most  prevalent  in  China  ;  and,  according  to  Hobson,  the  female 
breast  is  frequently  affected.  Desiring  to  obtain  some  recent 
information  on  this  subject,  I  lately  wrote  to  Dr.  Cantlie,  of 
Hong-Kong,  who  very  kindly  furnished  me  with  the  following 
details,  for  which  I  now  thank  him.  Referring  to  the  prevalency 
of  the  disease  he  says  :  "  I  do  not  think  I  have  been  without  a 
case  of  malignant  disease  under  my  care  ever  since  I  came  to 
China  six  years  ago."  Of  3,608  consecutive  Chinese  hospital 
in-patients  under  his  care,  114  had  cancer,  or  3-1  per  cent.  This 
proportion  is  almost  identical  with  that  met  with  in  large 
London  general  hospitals,  like  St.  Bartholomew's,  where  3-5 
per  cent,  of  the  in-patients  have  cancer.  Of  Cantlie's  114 
Chinese  cancer  patients,  the  primary  seats  of  the  disease  were 
as  follows  :  female  breast,  38  ;  upper  jaw,  25  ;  lower  jaw,  14  ; 
penis,  9  ;  uterus,  8  ;  parotid,  5  ;  hip,  5  ;  tongue,  4  ;  lip,  3  ;  and 
thigh,  3.  At  Dr.  Kerr's  hospital  in  Canton,  during  the  year 
1887,30  cases  of  malignant  disease  were  operated  on,  including 
1 1  amputations  of  the  female  breast.  Strange  to  relate,  Cantlie 
has  never  met  with  cancer  of  the  stomach  among  the  Chinese. 

^  The  cancer  mortality  for  1888-89  per  million  living  aged  25  and  upward.s,  was 
males,  2,313,  females,  3,515;  for  England  (1889)  the  corresponding  figures  were: 
males,  1,393,  females  2,038.  King  and  Newsholme,  P/oi:  Koy.  Society,  vol.  xiv.. 
No.  327,  p.  242. 


GEOGRAPHICAL     DISTRIBUTION.  25 1 

With  regard  to  their  diet  he  says  :  "  All  Chinamen  eat  fish  and 
pork  at  morning  and  evening  meals.  Fowls  and  ducks  are 
always  on  the  table  of  all  but  the  most  humble  of  the  coolie 
class ;  and  they  do  not  have  them  because  they  cannot  afford 
them.  I  hope  this  will  be  a  sufficient  answer  to  those  who 
maintain  that  Chinamen  live  on  rice.  It  is  not  nearly  so  true 
as  that  the  Scotch  live  on  porridge." 

In  India  cancer  is  said  to  be  rare  ;  but  neither  the  rice- 
eating  Hindoos,  nor  the  flesh-eating  Mohammedans  are  exempt. 
In  support  of  the  alleged  rarity  of  cancer  in  India,  Davidson  ^^ 
mentions  that  of  2,657  operations  performed  at  the  Afzulgung 
Hospital  at  Hyderabad  in  1886,  only  two  were  for  cancer; 
while  in  Bombay  only  T  per  1,000  of  the  total  deaths  were 
ascribed  to  it.  On  the  other  hand,  McLeod  ^^  states  that 
malignant  neoplasms  (cancer  and  sarcoma)  are  common  among 
the  natives  of  Bengal,  both  in  hospital  and  private  practice  ;  in 
females  the  breast  being  chiefly  aff'ected,  and  in  males  the 
cutaneous  system,  oral  cavity  and  especially  the  penis. 
Hendley's^^  experience  at  the  Jeypore  Hospital  seems  to 
accord  with  this,  for  during  the  period  1880-88,  when  the 
hospital  was  under  his  charge,  102  major  operations  were 
undertaken  for  the  treatment  of  malignant  disease.  As,  in  the 
face  of  these  conflicting  statements,  further  information  seemed 
desirable,  I  wrote  to  Surg.  Lieut-Col.  Lawrie,  of  Hyderabad, 
who  kindly  favoured  me  with  the  following  reply,  "  My  ex- 
perience of  cancer  is,  that  it  is  as  frequent  in  India  as  in 
Calcutta,  Lahore  and  Hyderabad.  The  Afzulgung  Hospital 
England  ;  and  I  have  formed  this  opinion  from  observation  in 
was  under  my  charge  in  1886,  and  that  year  was  no  exception 
to  the  rule.  The  small  number  of  operations  for  cancer  shows 
nothing,  except  that  the  people  are  averse  to  operation  for 
most  diseases,  other  than  stone  and  cataract." 


-*  "Geographical  Pathology,"  1892. 

**  "  Operative  Surgery  in  Calcutta,'"  1885,  p. 

^  British  Medical  /ournal,  July  7,  1888. 


252         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

In  Cashmere,  Orissa,  Madras,  Anam  and  Cochin,  cancer  is 
said  to  be  more  prevalent  than  in  adjacent  communities. 

In  Syria,  Persia  and  Arabia,  according  to  Lombard,  the 
disease  is  very  rare  ;  and  generally  speaking  it  is  not  common 
within  the  tropics. 

No  part  of  the  world  is  said  to  enjoy  such  relative  immunity 
from  cancer  as  Africa  ;  this  applies  to  nearly  all  parts  of  the 
continent,  but  especially  to  its  northern  part — Egypt,  Tunis, 
Algiers,  &c.  In  order  to  ascertain  the  present  state  of  things 
in  Egypt,  I  lately  wrote  to  Dr.  Engel  Bey,  of  Cairo,  who  very 
obligingly  sent  me  the  following  data.  Of  19,529  deaths 
among  natives  in  Cairo  during  1891,  only  nineteen  were  re- 
turned as  due  to  cancer  (females  10,  males  9).  or  one  in  1,028 ;  in 
England  during  the  same  year,  the  proportion  of  cancer  deaths 
was  I  in  29.  Of  12,950  patients  in  the  Kasr-el-Aini  Hospital 
during  the  years  1889-91,  "JJ  were  affected  with  cancer,  or  "6  per 
cent.;  whereas  in  Metropolitan  General  Hospitals  I  have  ascer- 
tained that  the  proportion  of  cancer  cases  is  about  3"5  per 
cent.  From  these  data  it  appears  that  the  reputation  of 
Egypt  for  comparative  immunity  from  cancer  is  well  founded. 
With  regard  to  the  prevalence  of  cancerous  diseases  in  Morocco, 
I  am  indebted  to  Mr.  Ernest  Hart  for  the  following  valuable 
information.  In  answer  to  my  letter  of  inquiry,  he  very  kindly 
wrote  to  Dr.  Terry,  of  Tangiers,  who  replied  as  follows : 
"  Cancers,  sarcomas,  &c.,  do  not  seem  to  be  very  prevalent ; 
at  any  rate  the  number  of  cases  met  with,  as  compared  with 
other  diseases,  shows  that  they  are  of  less  frequent  occurrence 
than  in  England.  Among  the  inhabitants,  who  are  of  mixed 
Arab  and  native  blood,  I  have  seen  cancers  of  the  female 
breast,  uterus  and  tongue  ;  as  well  as  sarcomatous  growths  in 
various  parts  of  the  body."  At  the  Cape,  cancer  is  common 
among  the  whites,  but  very  rare  among  the  natives.  Living- 
stone ^^  speaks  of  cancer  as  being  absent  from  the  Barotze 
Valley  and  among  the  Bakwains,  although  the  latter  are  prone 

-■'   "  Missionary  Travels  in  South  Africa,"  pp.  127  and  504. 


TOPOGRAPHICAL     VARIATIONS.  253 

to  fatty  and  fibrous  tumours.  In  Abyssinia  cancer  is  said  to 
be  commoner  than  in  any  other  part  of  Africa. 

Cancer  has  been  notified  in  Brazil,  Mexico,  Montevideo, 
Ecuador  and  Peru ;  but  as  to  its  relative  frequency  in  South 
American  countries  we  have  hardly  any  definite  information. 
According  to  Jourdanet  it  is  almost  unknown  in  the  hot  regions 
of  Mexico,  while  in  the  high  cool  regions  it  is  as  frequent  as 
in  Europe.  At  Rio-de-Janeiro  cancer  is  comparatively  rare 
and  tubercle  very  common.  Of  13,725  deaths  in  1890,  123 
were  due  to  cancer,  or  i  in  r  11  ;  and  2,200  to  tubercle.^^  In 
British  Guiana  the  cancer  mortality  in  1888  amounted  to  3  per 
cent,  of  the  total  deaths.  It  is  rare  in  Jamaica  (I'lp  per  10,000 
living  in  1888)  and  Mauritius  ("6  per  10,000  living  in  1889). 

In  our  Australian  Colonies  cancer  is  common,  especially  in 
Tasmania,  but  less  so  than  in  England.  The  following  are 
some  of  the  chief  ascertained  death  rates  per  10,000  living: — 
Tasmania  (1882-6),  4-8;  Victoria  (1882-6),  47;  New  Zealand 
(1888),  4-3;  W.  Australia  (1882-6),  3-8;  S.  Australia  (1882-6), 
3-2  ;'New  S.  Wales  (1882-6),  2-8  ;  Queensland  (1882-6),  2-4. 

Among  whites  cancer  is  fairly  common  in  all  parts  of 
British  North  America. 

In  every  part  of  the  world  the  distribution  of  cancer  presents 
many  topograpJiical  variations?^  Moore  ^°  was  one  of  the  first 
to  study  these  for  England  and  Wales.  He  showed  that  the 
disease  was  more  prevalent  in  London  and  the  adjacent 
southern  and  eastern  counties  than  elsewhere ;  and  that  it  was 
least  prevalent  in  Wales  and  in  the  north-western  (Lancashire) 
and  northern  counties.     If,  he  says,  the  country  be  divided  by  a 


'■^  Ilavelburg,  "  Beitrag.  z.  Trophenhygiene,"  Berlin  kliii.    IVoch.,  No.  14,  1892, 

s.  336. 

"''  In  the  United  States  cancer  is  much  more  prevalent  in  the  Northern  than  in 
the  Southern  States.  It  is  especially  frequent  in  New  England,  the  Southern  part 
of  the  Pacific  coast,  New  York,  Pennsylvania  and  Ohio.  In  Prussia  it  is  commonest 
in  Schleswig.  Lately  a  great  deal  of  attention  has  been  directed  to  its  prevalence 
in  certain  Normandy  villages,  St.  Sylvestre  de  Corneilles,  St.  Leones,  Ardeuse,  &c., 
(q.  V.  147.) 

^  "Antecedents  of  Cancer,"  1865,  p.  42. 


254 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


line  from  Bristol  to  Peterborough — which  practically  separates 
the  industrial  from  the  agricultural  communities — the  mortality 
from  cancer  in  the  southern  divisions  is  considerably  in  excess 
of  that  on  the  north  of  the  line.  In  the  year  1861,  for  instance, 
one  of  every  thirty  deaths  of  females  in  the  south-eastern 
(agricultural)  division  was  due  to  cancer ;  while  the  deaths  of 
females  from  cancer  in  the  north-western  (industrial)  division 
were  only  about  half  as  many,  or  one  in  fifty-nine  of  the  total 
female  mortality. 

Moore  gives  the  following  table  in  illustration  of  his  obser- 
vations, based  on  the  Registrar-General's  returns  for  the  ten 
years  1851-61. 


One  death  from  cancer 

One  death  from  cancer 

n 

female    population 

in    total    female    mor- 

iet 

Meen  ages  of  35  and 

tality  between  ages  of 

64. 

35  and  64. 

England  and  Wales 

(average) 

91 

...          15 

London 

67 

12 

South-Eastern  Division 

83            ... 

12 

South- Midland      ... 

89            ... 

...          13 

Eastern       

84            ... 

12 

South-Western 

100 

14 

West-Midland 

90 

14 

North-Midland      ... 

97 

...         14 

North-Western 

103 

20 

York            

100 

...         16 

Northern 

102 

...         16 

Wales          

137 

20 

In  the  Forty-Seventh  Annual  Report  of  the  Registrar- 
General  (1886),  this  subject  has  been  further  investigated. 

The  subjoined  table,  from  this  source,  shows  the  cancer 
mortality  in  the  registration  divisions  during  the  30  years 
1851-80:— 

Mean   Annual    Mortality  per   Standard    Million,  Aged  25  and 


Upwards. 

Males. 

Females. 

Persons. 

England  and  Wales  (ave 

rage) 

...    561    ... 

...    1,144    ... 

..       867 

London          

...    736    ... 

...     1,463    ... 

..  I.II7 

South-Eastern 

...    557    ... 

...     1,207    ... 

...       898 

South-Midland 

...    597    ... 

...     1,148    ... 

..     886 

Eastern          

...    502    ... 

...    1,175    - 

..     855 

TOPOGRAPHICAL      VARIATIONS. 


255 


Males.  Females.  Persons. 

West-Midland 519  1,133  ^41 

Yorkshire       511    1,114  827 

Northern       565   1,041  815 

South-Western         555  1,043  8" 

North-Western        523  1,055  802 

North-Midland         496  1,074  799 

Wales 538  841  697 

It   will  be  seen  that  the  results  brought  out  by  these  two 

tables  are  practically  identical. 

The  counties  with  the  highest  cancer  mortality^^  are  : — 

London,  Cambridgeshire,  Northamptonshire,  Huntingdonshire,  Sussex, 
Warwickshire,  Beds,  Surrey,  Middlesex,  Berks,  Devon,  Norfolk,  Hants, 
Notts,  Lincolnshire,  &c. 

Those  with  the  lowest  are : — 

Derbyshire,  South  Wales,  Bucks,  Herts,  Durham,  Cornwall,  Monmouth- 
shire, Dorsetshire,  North  Wales,  Lancashire,  &c. 

Haviland^^  gives  the  following  tables  showing  the  places 
having  the  highest  death  rates  from  cancer  ;  and  it  will  be  seen 
how  persistent  these  are  : 


A.     Places  with  the  Highest  Death  Rate  from 


Richmond  (Surrey) 

Pickering  (Yorks)   . 

Shrewsbury  . . 

Stafford 

Stratford-on-Avon  . 

Downham 

King's  Lynn.. 

Yarmouth 

Wangford 

Cambridge     . . 

Bury-St. -Edmunds. 

Witham 

Tilbury 

Marlborough 

Reading 

Droxford 

Chichester 

Ticehurst 

Brighton 

Romney  Marsh 

Plymton-St.-Mary  . 

Plymouth 


Mean  at  all  ages 

Mean  above  35  years  of  age 

Mean  at  all  ages  (England  and  Wales) 

Mean  above  35  (England  and  Wales)  . 


6-87 
6-6s 
6"73 
6-69 
6-6i 

6'20 

6  "so 

6-87 
i9"82 
4"34 


561-70. 
6-6i 


Cancer  among  Females, 
1851-60, 

•  7"3o 

. .  8-05 

••  7'i7 

..  7-47 

..  679 

. .  6*70 

..  7-09 

. .  7-64 

..  674 

..  7-38 

••  7'53 

..  6-56 

••  7"3o 

..  6-66 


•  »39. 

•  7'3S 
.  6-8i 

•  6-37 
.  6-98 

■  9"i5 

•  6'32 
.  8-15 
.  8-09 

770 

.  6'io 

•  3'55 
.  4*62 

•  873 

•  S'73 
.  8-23 

■  5  "50 

•  7'7i 
.  3-88 

■  6 '74 

■  7'23 

.  6-8i 

■  i9"97 

•  5"23 

•  i5'64 


^'  Corrected  for  .ige  and  sex  distribution, 
'^-  Lancet,  vol.  i.,  1SS8,  p.  366. 


256 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


B.      Places  with  Highest  Death  Rate  from  Cancer  among  M 


Thakeham    . . 

Ringwood 

Wellinghorough 

Huntingdon 

St.  Ives 

St.  Neots 

Cambridge    . . 

South  Molten 

Bristol 

Shrewsbury  . . 

Uttoxeter 

Nuneaton 

Solihull 

Reeth 

West  Ward 

Machynlleth 


1851-60. 

1861-70 

.        4-40        .. 

.     3-82 

4'oo     . . 

•     3'69 

•     3'70     •  ■ 

4'26 

370     . . 

.     6-71 

3-90     . . 

.     8-78 

3'8o     .  . 

•      4'50 

.     3'8o     .. 

4'22 

3'7o     •• 

4'oo 

3-80     ... 

.  3-38 

4'20       .  . 

•      4'07 

3-90    . . 

.      4-08 

3-80    ... 

•     479 

3"8o     .. 

■     4  "03 

3-70     . . 

■     3'77 

3'6o     .. 

•      4  "07 

4"oo     . . 

•      4'7o 

.     3-86     . . 

.      4-21 

■     II'2S 

.    I3'i6 

•      ''93     •• 

•      2 '44 

•     5-87     .. 

•     7'52 

Mean 

Above  35 

Mean  at  all  ages  (England  and  Wales) 

Above  35  (England  and  Wales)  . 


I  have  been  informed,  by  a  Jersey  practitioner,  that  cancer 
is  very  prevalent  there,  as  well  as  in  Guernsey.  In  order  to 
ascertain  the  extent  of  the  mortality,  I  wrote  to  the  gentle- 
man who  furnishes  the  mortality  statistics  for  Jersey,  to  the 
Registrar-General ;  but  no  information  has  been  forthcoming. 

The  foregoing  observations  refer  exclusively  to  the  deaf/i 
places  of  cancer  patients.  In  order  to  ascertain  whether  similar 
relations  hold  for  their  dz'rt/i  places,  I  have  noted  where  352 
consecutive  cancer  patients  were  born,  with  the  following 
results : — 

Of  242  females  (breast  91,  uterus  129),  70  were  born  in 
London,  54  in  other  towns,  and  118  in  the  country. 

Of  the  to'iv7i-bor7i,\\  were  from  England  :— Birmingham  (3),  Stowmarket 
(3),  Norwich  (2),  Newmarket  (2),  Rotherhithe  (2),  and  i  each  as  follows— 
Hungerford,  Aylesbury,  Southampton,  Yeovil,  Honiton,  Epping,  Shields,  St. 
Albans,  Bristol,  Scarborough,  Liverpool,  Hull,  Manchester,  Ely,  Worcester, 
Southsea,  Portsmouth,  Woolwich,  Plymouth,  Maidstone,  Devonport,  Wells, 
York,  Hemel-Hempstead,  Yarmouth,  Oxford,  Ipswich,  Harwich,  and 
Cheltenham.  Seven  were  from  Irish  towns — Dublin  (4),  Cork  (2),  Limerick 
(i).  Two  from  Wales— Bangor  (i),  Haverfordwest  (i).  Two  from  Scot- 
land—Edinburgh (i),  Leith  (i).  The  other  two  were  of  foreign  birth— the 
Hague  (i),  Warsaw  (i). 

Of  the  118  country-born  patients,  98  were  of  English  birth  :— Berks  (8), 
Devon  (8),  Herts  (8),  Surrey  (7),  Essex  (6),  Suffolk  (6),  Norfolk  (6),  Lincoln- 
shire (5),  Bucks  (5),  Gloucestershire  (5),  Kent  (5),  Hants  (5),  Northampton- 


TOPOGRAPHICAL    VARIATIONS.  257 

shire  (4),  Wilts  (4),  Cambridgeshire  (3),  Somersetshire  (3),  Beds  (3), 
Cheshire  (2),  Oxon  (2),  Middlesex  (2),  Cumberland  (2), and  i  each  as  follows : — 
Cornwall,  Leicestershire,  Notts,  Warwickshire,  Sussex,  Northumberland, 
and  Derbyshire.  One  was  of  Welsh  birth — from  Glamorganshire.  Nine 
were  Irish — Cork  (3),  Limerick  (2),  Kerry  (i).  North  (2),  and  South  (i). 
Three  were  Scotch — i  each  from  Roxburgh,  Dumbarton,  and  Dumfries. 

Of  1 10  male  cancer  patients  36  were  born  in  London,  24  in 
other  towns,  and  50  in  the  country. 

The  town-bo7'?i  patients  were,  from  Liverpool  (2),  Bristol  (2),  and  i 
each  as  follows  : — Guildford,  Bath,  Maidstone,  Lewes,  Devonport,  Man- 
chester, Deal,  Ipswich,  Buckingham,  Woolwich,  Sandhurst,  Cheltenham, 
Tewkesbury,  Reading,  Windsor,  Winchester,  Cork,  and  Aberdeen. 

The  country-born  patients  came  from  Cambridgeshire  (6),  Essex  (4), 
Herts  (3),  Kent  (2),  Lincolnshire  (2),  Devon  (2),  Berks  (2),  Norfolk  (2),  Bucks 
(2),  Dorset  (2),  Glamorganshire  (2),  Carmarthenshire  (2),  and  1  each  as 
follows  : — Gloucestershire,  Beds,  Sussex,  Somerset,  Hants,  Wilts,  Northamp- 
tonshire, Leicestershire,  Warwickshire,  Huntingdonshire,  Cornwall,  Isle  of 
Wight,  Isle  of  Man,  Pembrokeshire,  Cardiganshire,  Renfrewshire,  Co. 
Limerick,  near  Carlow,  and  near  Skibbereen. 

Of  1,030  consecutive  cases  tabulated  by  Nunn,^^  335  were 
born  in  London,  588  in  various  English  counties,  20  in  Wales, 
13  in  Scotland,  53  in  Ireland,  and  21  abroad.  The  English 
counties  that  furnished  most  of  the  cases  were  Kent,  Essex, 
Sussex,  Berks,  Hants,  Herts,  Middlesex,  Norfolk,  Suffolk,  Devon, 
Somerset,  Bucks,  and  Wilts  ;  while  those  that  furnished  fewest 
were  Isle  of  Wight,  Rutland,  Westmorland,  Huntingdonshire, 
Worcestershire,  and  Leicestershire. 

It  will  be  gathered  from  these  analyses  that  the  localities  of 
greatest  cancer  mortality  are  also  its  most  frequent  birthplaces. 

These  remarkable  topographical  variations  are  regarded  by 
Haviland^'^  as  entirely  due  to  geological  configuration  and  its 
consequences.  He  maintains  that  the  regions  of  highest  cancer 
mortality  are  low-lying  districts,  traversed  by,  or  contiguous  to, 
rivers  that  seasonally  flood  the  adjacent  riparial  lands  ;  whereas 
the  lowest  cancer  mortality  is  found  in  high  and  dry  sites,  where 


•*■'  "  Cancer  of  the  Breast,"  1882,  p.  165. 

■"  "  Geographical  Distribution  of  Heart  Disease,  Cancer,  and  Phthisis  in  England 
and  Wales,"  London,  1892. 

^7 


258         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

floods  do  not  occur,  and  where  the  subsoil  consists  of  hard,  non- 
retentive  rocks  {e.g.,  English  lake  district)  ;  or  of  absorbent  sub- 
stances like  chalk  and  oolite.  In  support  of  these  views,  he 
instances  the  Thames  and  its  tributaries,  which  run  through  a 
vast  cancer-field,  and  he  points  to  the  only  localities  in  the 
lower  Thames  valley — the  Orsett  and  Dartford  districts — where 
there  is  a  low  cancer  mortality,  as  being  just  those  spots  where 
the  chalk  crops  out. 

In  favour  of  the  opinion  that  in  this  country  cancer  is 
specially  prevalent  in  flat,  low-lying,  fenny  districts,  there  is,  I 
think,  much  to  be  said.  The  forty-seventh  report  of  the  Regis- 
trar-General shows  that  Cambridgeshire  and  the  adjacent  coun- 
ties of  Northamptonshire,  Huntingdonshire  and  Bedfordshire, 
all  have  very  high  cancer  mortality.  Lincolnshire  and  Essex 
figure  less  prominently  in  this  report ;  but  my  analyses  show 
that  the  number  of  cancer  patients  born  in  these  localities  is 
exceedingly  high.  Nevertheless,  I  am  unable  to  accept 
Haviland's  views  as  a  sufficient  explanation  of  the  topogra- 
phical variations  in  the  distribution  of  cancer.  All  low-lying 
and  seasonally  flooded  districts  have  not  a  high  cancer  mor- 
tality ;  the  very  large  area  drained  by  the  Severn  and  its 
tributaries,  for  instance,  has  throughout  a  low  average  mortality 
from  this  disease.^'' 

It  appears  to  me  that  the  explanation  of  these  variations 
must  be  sought  in  the  conditions  of  life  peculiar  to  the  respective 
populations. 

Generally  speaking  the  cancer  mortality  is  lowest  where  the 
struggle  for  existence  is  hardest,  the  density  of  population 
greatest,  the  tubercle  mortality  highest,  the  average  duration  of 
life  shortest,  the  general  mortality  highest,  and  wJiere  sanitation 
is  least  perfect — in  short,  among  the  industrial  classes  ;  whereas, 
among  the  wealthy  and  well-to-do— where  the  standard  of 
health  is  at  its  best  and  life  is  easiest — and  among  the  agricul- 
tural community,  there  the  cancer  mortality  is  highest.     Other 


**  "  Registrar-General'.s  Forty-Seventh  Report,    Table  J.,  p.  21, 


TOPOGRAPHICAL     VARIATIONS.  259 

things  being  equal,  there  are,  in  my  opinion,  no  more  potent 
factors  in  the  causation  of  cancer  than  high  feeding  and  easy 
living.  Hence  it  is  that  the  cancer  mortality  of  mining  and 
industrial  centres  like  South  Wales,  Lancashire,  Durham,  Corn- 
wall, West  Riding,  &c.,  is  so  low ;  and  that  it  contrasts  so 
favourably  with  the  cancer  mortality  of  the  generality  of  agri- 
cultural districts.  Although  the  ratio  of  pauperism  in  the  rural 
districts  is  quite  double  that  of  the  industrial  ones,  I  have  no 
hesitation  in  saying,  as  the  result  of  my  own  observation  of  life 
under  both  conditions,  that  so  far  as  food  and  comfort  are 
concerned,  the  agricultural  labourer  is  much  better  off  than 
his  more  highly  paid  confrere  of  the  industrial  army. 

On  the  other  hand,  in  London  and  the  home  counties,  where 
the  wealth  of  the  nation  is  clotted,  there  the  cancer  mortality  is 
highest  ;  and  it  is  a  significant  fact  that  this  mortality  is  highest 
of  all  in  those  parts  of  the  metropolis  where  the  well-to  do  most 
abound. 

According  to  the  Registrar-General's  Report  for  1884,  the 
cancer  mortality  of  the  chief  metropolitan  districts  was  as 
follows  : — 

fF^i'/.— Chelsea,  i  in  647  ;  Marylebone,  1  in  890;  St.  George's,  Hanover 
Square,  i  in  1,109;  Kensington,  i  in  1,251  ;  Fulham,  i  in  1,292  ;  West- 
minster. I  in  1,369.  East. — Whitechapel,  i  in  839  ;  Mile  End,  i  in  2,200  ; 
Poplar,  I  in  2,173  !  St.  George's-in-the-East,  i  in  2,245  '■>  Stepney,  i  in  2,341  ; 
Shoreditch,  i  in  2,482  ;  Bethnal  Green,  i  in  2,885.  Average  for  all  Lofrdon, 
I  in  1,465  ;  average  for  Eiigland  and  Wales,  i  in  1,786. 

Cripps,*  taking  an  average  of  ten  years,  found  the  cancer  mortality  of 
IVesl  London,  double  that  of  the  Easl. 

Of  69  London-born  cancer  patients  interrogated  by  me  at  the  Middlesex 
Hospital,  23  were  born  in  the  IVesl,  15  in  the  Easl,  14  in  the  North,  7  in  the 
South,  3  in  the  City,  and  7  in  districts  not  stated. 

Of  476  patients  from  London  under  treatment  at  the  Brompton  Cancer 
Hospital  in  1889,  154  came  from  the  Soiith-West  di\'s,\.x\(z\.,  93  from  the  West, 
89  from  the  Soiith-East,  54  from  the  East,  40  from  the  North,  30  from  the 
North-  West,  and  3  from  the  West  Central. 

For  some  of  our  large  towns  the  cancer  death  rates  are  as  follows  : — 
Manchester,  i  in  1,566;  Salford,  i  in  1,994;  Liverpool,  i  in  1,604;  Preston,  i 
in  1926;  Bradford,  i  in  1,822  ;    Leeds,  i  in  1,413;    Birmingham,  i  in  1,520  ; 


British  Medical  your iial,  April  22,  1SS4. 


26o        GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

Norwich,   i  in    1,440;    Newcastle,   i   in  1,855  '>    Durham,  i   in  2,573  ;    Not- 
tingham,  I  in   1,488. 

What  a  contrast  with  these  is  well-to-do,  easy-going  Richmond,  with  a 
cancer  mortality  of  i  in  960  ! 


S     IV. — -Family  History. 

(a)   TJie  Heredity  of  Cancer. 

Very  conflicting  are  the  views  now  prevalent  as  to  the  Jiere- 
ditability  of  cancer.  On  the  one  hand  are  those  who  regard 
this  as  an  impossibihty ;  and  on  the  other  those  who  cannot 
conceive  an  explanation  of  the  disease  without  it.  These  con- 
tradictory opinions  are  no  doubt  largely  attributable  to  VVeis- 
mann's  teaching,  which  has  wrought  such  confusion  in  the 
fundamental  conceptions  of  heredity.  I  cannot  here  enter  on 
the  burning  question  of  Weismannism  versus  Darwinism  : 
suffice  it  to  say  that  I  regard  Wcismann's  doctrine  of  the  non- 
hereditability  of  acquired  variations  as  improbable.^^  The  first 
principles  being  in  this  unsettled  state,  it  will  be  best  to  pass 
at  once  to  the  facts. 

An  analysis  of  the  records  of  136  consecutive  cases  of  cancer 
of  the  female  breast,  from  data  collected  by  myself,  gives  the 
following  results. 

There  was  a  history  of  cancer  in  }^}^  families,  or  in  24*2  per 
cent.^^ 

The  relatives  thus  arfected  and  the  seats  of  the  disease  were 
as  follows  :  — 


"*  The  distinction  between  somatic  and  oerni.  cells,  on  which  Weismann's  theory 
is  based,  appears  to  me  to  be  entirely  artificial.  I  believe  that  the  reproductive  pro- 
perties manifested  by  somatic  and  germ  cells  are  the  same  in  kind  and  that  they 
differ  only  in  degree. 

'■"  From  whatever  point  of  view  the  subject  is  regarded,  this  is  a  very  high  per- 
centage. Many  anomalies,  well  known  to  be  hereditary,  yield  on  inquiry  a  much 
lower  proportion  ;  for  instance,  of  92  cases  of  supernumerary  mammary  structures 
analysed  by  Leichtenstern,  there  was  history  of  heredity  only  in  7,  or  in  7*6  per  cent. 


FAMILY    HISTORY. 


261 


Father's  father  (in  2  families) 
Father's  mother  (in  2  families) 


j  Nose. 

\  (Esophagus. 

J  Breast. 
)  Breast. 


First  cousin  of  father's  mother  (in    i  ")  ..^^       , 
f.r^iWA  C  CEsophagus, 


family) 
Father  (in  5  families) 


Father's  sister  (in  10  families) 

Mother's  mother  (in  3  families)     ... 
Sister  of  mother's  father  (in  i  family) 

Mother  (in  7  families; 
Mother's  sister  (in  6  families) 


[  Breast. 

Lip. 

Hand. 

Internal. 
I  Liver. 

Breast  (5). 

Mouth. 

Face. 

Scalp. 

Liver. 

Internal. 

Breast. 
Uterus. 
Locality  not  stated. 

Breast. 

'  Uterus  (2). 

Stomach. 
i  Breast. 

Tongue. 
V  Internal  (2). 

r Breast  (4). 

■<  Internal. 

(Tongue. 

Mother's  brother  (in  i  family)        . . .  Groin. 

Female  cousin  on  mother's  side  (in  2  J  Breast. 

(  Locality  not  stated. 

(Breast  (3). 


families). 
Patient's  sister  (in  5  families) 


i  Uterus, 
Locality  not  stated. 

j  Throat. 
(  Back. 

Internal. 


Patient's  brother  (in  two  families).. 

Patient's  daughter  (i   family) 

These  48  seats  of  hereditary  disease  may  be  grouped  thus 
breast  19,  internal  6,  uterus  4,  liver  2,  oesophagus  2,  all  others  15 
In  8  cases  ^nore  than  a  single  relative  zuas  affected,  thus  : 


262         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

(i)  Father's  father,  aged  60,  and  first  cousin  of  father's  mother,  both 
died  of  cancer  of  oesophagus  ;  the  patient  was  47  years  old. 

(2)  Father,  aged  71,  mother,  and  mother's  sister,  all  died  of  internal  can- 
cer ;  the  patient  was  45  years  old. 

(3)  Father  died,  aged  42,  of  cancer  of  the  breast  ;  father's  two  sisters--- 
one  of  the  breast,  age  52,  the  other  of  the  liver  ;  and  two  of  patient's  sisters, 
both  of  the  breast  ;  and  patient's  brother  died  of  tumour  of  the  back,  aged 
30  ;  the  patient  was  yj  years  old. 

(4)  Father's  sister  and  daughter  of  mother's  sister  both  died  of  cancer  of 
the  breast  ;  the  patient  was  59  years  old. 

(5)  Father's  sister  (aged  75),  of  the  scalp  ;  mother  (aged  54)  and  patient's 
sister  (aged  59),  both  internal  ;  the  patient  was  46  years  old. 

(6)  Mother  died  of  cancer  (locality  not  stated),  and  mother's  brother  died 
of  cancer  of  groin  ;  the  patient  was  60  years  old. 

(7)  Father's  mother  and  patient's  sister  (aged  48)  both  died  of  cancer  of 
breast  ;  the  patient  was  5 1  years  old. 

(8)  Father's  sister  died  (aged  40)  of  cancer  of  mouth,  and  another  of  his 
sisters  died,  at  about  the  same  age,  of  cancer  of  the  eyelid  ;  the  patient  was 
47  years  old. 

In  four  cases  there  was  history  of  cancer  in  the  families  of 
both  parents. 

(i)  Father,  of  the  liver,  and  mother,  of  the  breast. 

(2)  Father,  mother,  and  mother's  sister,  all  internal. 

(3)  Father's  sister  and  mother's  sister,  both  of  breast. 

(4)  Father's  sister,  of  scalp  ;  mother  and  patient's  sister,  both  internal. 

From  this  we  learn  that  while  in  some  families  cancer  had 
never  before  been  known  to  have  occurred,  in  others  several  of 
the  members  had  been  affected  in  successive  generations,  and  in 
half  of  the  latter  cases  the  affected  relatives  were  all  on  one  side. 

Let  us  now  turn  our  attention  to  these  cases  of  multiple 
family  cancer,  for  they  will  well  repay  careful  study. 

In  addition  to  those  above  mentioned,  I  will  cite  five  other 
remarkable  instances  of  this  kind  :  — 

(i)  A  woman,  aged  53,''^  came  under  my  observation  with 
uterine  cancer,  whose  maternal  grandmother,  mother  (aged  45), 
mother's  sister,  and  the  patient's  two  sisters  (aged  32  and  36), 
had  all  died  of  cancer  of  the  uterus. 

(2)  In  a  case  recorded  by  Sibley,  a  mother  and  her  five 
daughters  all  died  of  cancer  of  the  left  breast. 


•"  She  was  one  uf  a   family  of  eleven  ;    oi  her  brothers  and  sisters,  three  died  in 
infancy,  and  five  were  still  alive  and  well. 


FAMILY    HISTORY.  263 

(3)  Of  the  celebrated  Bonaparte  family,  Napoleon  I.,  his 
father,  his  brother  Lucien,  and  two  of  his  sisters,  all  died  of 
cancer  of  the  stoviacJi. 

(4)  The  following  case,  recorded  by  Broca,^^  is  the  most  com- 
plete of  its  kind  that  has  ever  been  published  ;  and  this  is 
mainly  due  to  the  fact  that  the  family  included  an  eminent 
physician  among  its  members,  who  furnished  the  particulars  as 
under : — 

First  Generation. — Madame  Z.  died  of  cancer  of  the  breast  (1788),  aged 
60.     She  left  four  daughters — A,  B,  C  and  D. 

Second  Generation. — The  four  daughters  of  Madame  Z. — 

(i)  Madame  A.  died  of  cancer  of  liver,  aged  62  (1820). 

(2)  „  B.     „  „  „         „     43  (1805). 

(3)  „  C.     „  „  breast     „     51  (1814). 

(4)  „  D.     „  „  „  „     54  (1827). 

Third  Generation. — Madame  A.  had  three  unmarried  daughters,  who  are 
still  alive  and  well,  aged  68,  72  and  78  years. 

Madame  B.  had  five  daughters  and  two  sons.  First  son  died — not  can- 
cerous— at  the  age  of  28,  and  without  issue.  Second  son  died  of  cancer  of 
stomach,  aged  54,  and  without  issue. 

First  daughter  died  of  cancer  of  breast,  aged  35         ^  All 

Second     „  ,,  „  „  „     35 — 45  I     unmarried. 

Third       „  „  „  „  „     35— 45  |   and  without 

Fourth     ,,  „  „  Hver,         „     35 — 45J         issue. 

Fifth         „  „  not  cancerous,  aged  60,  married,  but  no  issue. 

Madame  C.  had  five  daughters  and  two  sons  : — 
First  son  died  in  the  army,  without  issue. 

He  had  a  son  who  died  para- 
plegic, aged  18  ; 
Second  son  alive  and  well,  aged  72.        -^  and    an    only  daughter,  who  is 

now  alive  and  well,  aged  24, 
unmarried. 


First  son,  aged  58,  alive  and 
well.  He  has  three  sons 
alive  and  well — the  oldest  30. 

Second  son  died  young,  abroad, 

without  issue. 

„.         1       1  .       J-    1     r  r  -1        First  daughter  died  in  child-bed, 

First  daughter  died  of  cancer  of  the  I      ^bout  ""S 

breast,    aged   2,7,  leaving  two  sons^  gecond  daughter   died   of  can- 
and  three  daughters.  \     ^^^    ^f  ^^^   ^^^^^^^  ^^^^  ^^ 

She  left  two  daughters  ;  both 
are  alive  and  well  ;  the  elder 
is  now  22. 
Third  daughter  died  of  phthisis, 
\    aged  41. 


**  Traiti  des  Ttuneurs,  t.  i.,  1866,  p.  151. 


264         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

Second    daughter    died,    aged    40,    of  (  She  left  an  only  son,  who  is  still 
cancer  of  breast.  i      alive  and  well. 

Third  daughter  died,  aged  47,  of  can- 1   ^^ 

cer  of  uterus.  )   Unmarried. 

Fourth    daughter    died,    aged    55,    of  1  She  left  two  sons,  who  are  alive 

cancer  of  the  breast.  I      and  well. 

Fifth  daughter  died,  aged  61,  of  can- 1    ,^  .    , 

cer  of  liver.  )    Unmarried. 

Madame  D.  had  an  only  son,  who  is  alive  and  well,  aged  70. 

(5)  In  a  case  recorded  by  Warren,*''  the  father  had  cancer  of 
the  loiver  lip,  his  son  and  two  daughters  each  had  cancer  of  the 
breast;  in  the  succeeding  generation  a  daughter  of  this  son,  and 
a  daughter  of  one  of  his  sisters,  each  had  cancer  of  the  breast. 

These  cases  of  multiple  family  cancer  in  successive  genera- 
tions— which  are  not  so  rare  as  is  generally  believed,  for  I  have 
found  them  in  nearly  6  per  cent,  of  all  cases — prove  conclusively 
the  hereditability  of  cancer.^^  They  indicate  that  the  cause  of 
the  disease  must  be  sought  in  intrinsic  rather  than  in  extrinsic 
conditions. 

In  studying  this  subject  it  must  be  borne  in  mind  that 
morbid  conditions,  like  other  recently  acquired  characters,  are 
never  reproduced  in  the  offspring  with  the  same  constancy  and 
regularity  that  normal  conditions  are.  In  the  long  run  the 
tendency  always  is  to  normality  rather  than  to  abnormality. 
Hence  cancer  and  all  diseases  tend  to  die  out  in  the  course  of 
transmission.  So  great  is  the  preponderating  influence  of  the 
previous  ancestral  balance,  that  even  in  families  where  heredi- 
tary tendency  is  strongest,  most  of  the  members  usually  escape. 
Hence  my  analysis  shows  only  about  8  per  cent,  of  inheritance 
directly  from  parents. 

As  an  example  of  this  prophylactic  power  of  heredity — 
now-a-days  generally  overlooked — reference  may  be   made  to 


^^  "Surgical  Observations  on  Tumours,"  p.  281. 

^'  Virchow  cites  some  remarkable  instances  of  the  hereditary  transmission  of 
melanomata  in  horses.  In  one  of  these  a  young  white  stallion,  with  melanosis 
of  the  anus,  transmitted  this  disease  to  all  its  white  descendants,  while  those  of 
darker  colour  escaped.  From  horses  thus  bred  the  diseasi;  became  widely  spread 
throughout  the  neighbouring  country  side.     {Path,  des  Tumeurs,  I.  ii.,  p.  236.) 


FAMILY    HISTORY,  265 

the  transmission  of  deaf  mutism.  Buxton's  researches  shovv 
that  of  303  marriages  in  which  botJi  of  the  contracting  parties 
were  deaf  and  dumb,  only  one  in  twenty  of  the  offspring  were 
similarly  affected;  and  that  of  310  deaf  mutes  married  to 
hearing  people,  the  proportion  of  deaf  and  dumb  among  the 
offspring  amounted  only  to  one  in  135. 

It  is  difficult  to  apply  this  kind  of  treatment  to  the  family 
histories  of  cancer  cases  because  both  parents  are  very  rarely 
thus  affected  ;  moreover,  cancer  being  a  disease  of  adult  life, 
the  liability  to  it  of  those  of  the  offspring  who  die  young,  and 
of  those  who  are  still  living,  are  disturbing  factors.  Neverthe- 
less, in  spite  of  these  sources  of  fallacy,  I  think  the  following 
analyses  have  some  utility.  Of  136  family  histories  of  breast 
cancer  patients  investigated  by  me,  in  only  two  instances  were 
botli  parents  cancerous.  These  marriages  produced  seven 
children,  of  whom  two  had  died  of  cancer,  or  one  in  3*5.  Seven 
marriages  in  which  only  one  parent  was  cancerous,  produced 
sixty-two  children,  of  whom  ten,  or  one  in  6*2  had  become 
cancerous.  Six  marriages  in  which  although  neither  parent 
was  cancerous,  the  disease  existed  in  their  collatei^als,  produced 
forty-one  children,  of  whom  eight,  or  one  in  5"i,  had  become 
cancerous.  Here,  as  in  the  case  of  deaf  mutism,  the  tendency 
of  the  disease  liability  to  diminish  in  transmission  is  well  seen. 

In  physiological  heredity  it  is  a  generally  accepted  rule  that 
the  descendants  of  an  individual  in  whom  a  new  variation  has 
appeared,  are — other  things  being  equal — more  likely  to  vary 
again  in  a  similar  way,  than  are  persons  whose  ancestors  have 
never  manifested  such  variation.  That  the  same  tendency,  in 
a  less  degree,  holds  also  for  cancer  heredity,  I  have  not  the 
slightest  doubt,  although  attempts  have  been  made  to  prove 
the  contrary  by  ingenious  statistical  computations.'*- 


'"  In  his  report  for  1889  the  Registrar-General  writes  as  follows  ;  "  Seeing  that 
one  of  twenty-one  males  and  one  of  twelve  women,  who  reach  the  age  of  35,  die 
eventually  of  cancer,  it  follows  by  the  law  of  probabilities  that  on  an  average  in  one 
of  three  either  a  parent  or  grandparent  will  have  died  of  such  an  affection,  supposing 
such  parents  or  grandparents  to  have  died  after  35  ;  and  the  proportion  will  be  still 


266         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

This  opinion,  in  addition  to  the  above-mentioned  data,  is 
based  upon  the  following  evidence  •  — 

(i)  That  derived  from  the  study  of  multiple  family  cancers. 
Thus,  in  Broca's  celebrated  case,  of  the  twenty-six  descendants 
of  Madame  Z.  who  attained  or  exceeded  the  age  of  30,  fifteen 
died  of  cancer ;  whereas  the  cancer  mortality  for  the  same 
number  of  persons  of  the  general  population,  at  the  correspond- 
ing period  of  life,  is  considerably  less  than  one  ;  that  is  to  say, 
the  liability  to  the  disease  was  increased  more  than  fifteen  times 
by  the  influence  of  heredity. 

(2)  That  derived  from  comparing  the  proportion  of  cases 
with  family  history  of  cancer  among  the  cancerous  and  the  non- 
cancerous. Thus,  of  my  136  cases  of  cancer  of  the  female 
breast,  there  was  history  of  cancer  in  thirty-three  families,  or  in 
24'2  per  cent.  ;  whereas  of  ninety-five  cases  of  non-malignant 
tumours  and  cysts  in  women  there  was  history  of  cancer  only 
in  fourteen  families,  or  in  147  per  cent.^''  Hence  in  these  cases 
the  liability  to  the  disease  was  increased  nearly  10  per  cent,  by 
the  influence  of  heredity.  The  above  data  were  collected  by 
myself,  and  the  inquiries  were  equally  carefully  carried  out  in 
both  sets  of  cases.* 

The  phenomena  of  inheritance  teach  us  that  the  actual 
product  of  a  fertilised  germ  never  represents  the  full  measure 


higher  if  the  circle  of  relatives  is  extended  so  as  to  include  not  only  these  direct 
progenitors,  but  collateral  relatives  such  as  uncles  and  aunts."  The  appositeness  of 
this  seductive  chain  of  reasoning  is,  of  course,  entirely  dependent  upon  the  absolute 
correctness  of  the  premisses  on  which  it  is  based  ;  and  of  this  we  have  no  guarantee. 
The  results  arrived  at  are  so  completely  at  variance  with  the  very  plain  facts  cited 
by  me,  whose  accuracy  hardly  admits  of  dispute,  that  1  confidently  conclude  some 
error  has  crept  in.  Just  so  is  it  with  Cripp's  calculation  (S/.  Bartholomeio's  Hospital 
Reports,  vol.  xiv.,  p.  287)  in  which  he  has  attempted  to  prove  that  cancer  in  the 
parent  in  no  way  increases  the  liability  of  the  offspring  to  suffer  from  the  same 
disease. 

"  Fibro-adenoma  of  breast  thirty-eight  cases,  with  family  history  of  cancer  in  five  ; 
lipoma  thirty-six  cases,  with  family  history  of  cancer  in  six  ;  ovarian  cysts  twenty-one 
cases,  with  family  history  of  cancer  in  three. 

*  Of  147  cases  of  non-malignant  neoplasms,  whose  family  history  was  analysed 
by  Paget  {^Medical  Times  and  Gazette,  August  22,  1857,  p.  191),  only  6.8  per  cent. 
were  aware  of  having  had  cancerous  relatives. 


FAMILY    HISTORY.  267 

of  its  potentiality.  Only  a  portion  of  the  many  varying  tend- 
encies inherited  by  the  reproductive  cells  from  their  long  line 
of  ancestors  are  actually  evolved  in  each  generation.  Hence, 
in  normal  heredity,  we  constantly  see  transmitted  besides 
developed  structures,  certain  tendencies  and  predispositions. 
Thus  the  male  and  female  secondary  sexual  characters  are 
transmitted  through  each  sex,  though  usually  developed  in  one 
alone.  Similarly,  tendencies  are  transmitted  through  the 
earlier  years  of  life  that  are  only  subsequently  developed.  In 
like  manner  we  often  see  qualities  transmitted  in  a  latent  state 
through  one  or  more  generations,  and  then  suddenly  developed, 
as  in  the  wonderful  phenomena  included  under  the  term  re- 
version. By  virtue  of  these  considerations  it  has  been  truly 
said,  that  to  know  a  man  well  we  must  know  his  relations — 
grandparents,  parents,  uncles,  aunts,  cousins,  brothers,  sisters, 
children — in  them  we  shall  often  see  developed  his  own  latent 
tendencies.  For  this  reason  those  who  neglect  collaterals  in 
studying  heredity  are  greatly  in  error.  Such  are  the  physio- 
logical conditions  that  must  be  borne  in  mind  when  studying 
the  inheritance  of  cancer.'^* 

It  will  generally  be  found  that  the  birth  of  the  subjects  of 
direct  cancer  heredity  dates  from  a  period  long  anterior  to  that 
at  which  the  disease  appeared  in  their  parents.  Thus,  in 
Broca's  case,  the  four  daughters  of  Madame  Z.,  who  all  died 
cancerous,  were  born  fifteen,  twenty-five,  twenty-six,  and  thirty 
years  respectively  before  the  period  when  their  mother  died  of 
the  disease :  that  which  was  latent  in  the  parent  was  trans- 
mitted potentially  to  the  offspring. 

It  frequently  happens  that  such  latent  tendency  to  the 
disease    in    ancestors,  although    it  never    becomes    effective  in 


*'  According  to  Darwin's  hypothesis  of  pangenesis  every  cell  of  the  body  throws 
off  gemmules  or  undeveloped  atoms,  which  are  transmitted  to  the  offspring  of  both 
sexes,  and  are  multiplied  by  self-division.  They  may  remain  undeveloped  during 
the  early  years  of  life  or  during  successive  generations  ;  and  their  development  into 
cells  like  those  from  which  they  were  derived,  depends  on  their  affinity  for,  and 
union  with,  other  cells  previously  developed  in  the  due  order  of  growth. 


268         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

them,  nevertheless  does  so  in  their  descendants.  Thus  cases 
occur  in  which  cancerous  grandparents  transmit  the  disease  to 
their  grandchildren,  while  their  own  offspring  escape  {atavism). 
This  happened  in  seven  of  the  136  cases  of  cancer  of  the  female 
breast  analysed  by  me,  or  in  5"i  per  cent.  In  three  of  these 
cases  the  disease  was  inherited  from  the  maternal  grandmother, 
in  two  from  the  paternal  grandmother,  and  in  two  from  the 
paternal  grandfather.  In  three  cases  the  locality  affected  in 
the  grandparents,  as  in  the  grandchildren,  was  the  breast;  in 
the  other  four  cases  the  localisation  of  the  disease  in  the  grand- 
parents differed  from  that  in  the  grandchildren.  Whether 
cancer  is  ever  transmitted  by  reversion,  after  skipping  more 
than  a  single  generation — as  often  happens  in  physiological 
heredity — I  am  unable  to  state,  and  I  know  of  no  facts  bearing 
on  this  point. 

Much  commoner  than  true  atavism,  or  than  heredity  by  direct 
descent  from  parents,  is  a  form  of  inheritance  in  which  the 
disease  is  transmitted  through  parents,  &c.,  who  themselves 
never  manifest  it,  although  their  sisters,  brothers,  or  other 
relatives  do.  On  reference  to  my  analysis  it  will  be  seen  that 
the  inherited  disease  manifested  itself,  in  this  way,  in  the  father's 
sisters  in  ten  families,  the  breast  being  the  organ  affected  in 
five  ;  and  in  six  families  in  the  mother's  sisters,  the  breast  being 
affected  in  four. 

It  will  be  gathered  from  the  foregoing  that  what  is  trans- 
mitted in  cancer  heredity  is  not  the  disease  itself,  but  a  tendency 
or  predisposition  to  the  production  of  those  conditions  that  may 
finally  eventuate  in  it.  It  is  a  legitimate  inference  from  what 
has  been  stated,  that  the  special  tendency  to  cancer  is  of  gradual 
evolution  ;  and  that  without  this  antecedent  preparation  the 
disease  can  never  be  developed  under  ordinary  circumstances. 

A  remarkable  feature  about  many  cases  of  inherited  cancer 
is  that  the  disease,  like  normal  structure,  is  homotopic  in  its 
transmi-ssion  ;  that  is,  it  attacks  the  corresponding  organ  in  each 
of  the  related  individuals.  This  is  especially  noticeable  in 
Sibley's  case,  where  the   mother  and  her  five  daughters  all  had 


FAMILY    HISTORY.  269 

cancer  of  the  left  breast.  Although  this  form  of  transmission 
often  defaults,  it  is  nevertheless  noteworthy  that,  on  the  average 
— taking  all  the  seats  of  inherited  cancer  into  consideration  — 
homotopic  transmission  preponderates.  Thus,  of  the  forty-eight 
seats  of  inherited  cancer  in  my  analysis  of  the  family  history  of 
136  cases  of  mammary  cancer  in  women,  the  breast  was  the 
organ  affected  in  nineteen  ;  similarly,  of  the  fifteen  seats  of  the 
disease  inherited  from  Madame  Z.,  who  had  mammary  cancer, 
in  nine  the  breast-  was  affected.  The  tendency  to  homo- 
topic  transmission  may  thus  be  taken  as  the  established  rule, 
although  the  number  of  cases  in  which  heterotopic  transmission 
occurs  is  by  no  means  inconsiderable.  I  can  discover  no  ground 
for  the  dictum  that  homotopic  transmission  is  especially  apt  to 
prevail  among  near  relatives  and  heterotopic  transmission  among 
distant  ones.  In  ten  instances  of  mammary  cancer  inherited 
directly  from  one  or  both  parents,  in  only  two  was  the  breast 
the  locality  affected  in  the  ascendants.  From  the  foregoing  facts 
it  may  be  inferred,  that  the  molecular  protoplasmic  disturbance 
which  eventuates  in  inherited  cancer,  affects  the  whole  of  the 
archiblastic  tissues  of  the  body  ;  but  that  its  influence  is  most 
felt  in  that  part  which  corresponds  to  the  seat  of  the  disease  in 
the  ancestor. 

Inherited  cancer  manifests  itself  much  more  frequently  in  the 
female  than  in  the  male  relatives,  although  the  disease  is  as 
often  derived  from  the  father's  as  from  the  mother's  side  of  the 
family.  My  analysis  shows  this  very  well  ;  thus  of  forty-seven 
affected  individuals,  there  were  ten  males  to  thirty-seven  females. 
In  cases  of  multiple  family  cancer  this  tendency  of  the  inherited 
disease  to  repeat  itself  unduly  in  the  female  sex  is  especially 
noticeable.  Thus,  in  Broca's  case,  all  the  persons  attacked  but 
one  were  females.  Of  the  nineteen  daughters  and  grand- 
daughters of  Madame  Z.,  who  attained  the  age  of  30,  fourteen 
became  cancerous  ;  but  out  of  seven  males  only  one  was  thus 
affected. 

As  in  normal  heredity — but  with  less  constancy — cancer 
tends  to  appear  in  the  offspring  at  about  the  same  age  that  it 


270         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

appeared  in  the  ancestor.  Hence,  like  gout,  cataract,  phthisis, 
insanity,  and  some  other  heritable  conditions,  the  disease  usually 
does  not  manifest  itself  until  an  advanced  period  of  post- 
embryonic  life. 

It  has  been  suggested  that  during  the  course  of  its  trans- 
mission by  inheritance,  cancer  may  be  transmuted  into  sarcoma 
or  some  form  of  non-malignant  neoplasm.  On  a  priori  grounds, 
I  have  no  objection  to  offer  to  this  suggestion  ;  but  the  facts 
collected  by  me  show  that  the  existence  of  such  a  coincidence 
in  the  family  history  of  cancer  patients  is  very  exceptional. 
Of  the  136  family  histories  of  women  with  breast  cancer 
there  were  only  two  undoubted  instances  of  non-malignant 
neoplasms  in  relatives ;  in  one  case  the  patient's  mother,  who 
was  still  alive  and  well,  aged  75,  had  a  "  tumour"  removed  from 
her  thigh  when  she  was  50  years  old,  which  never  recurred  ;  in 
the  other,  the  patient's  father,  who  was  still  alive  and  well,  had 
a  lipoma  of  the  back.  Two  other  instances  of  so-called  "  tumour," 
one  "  internal  "  and  the  other  "abdominal,"  were  also  reported, 
one  in  a  patient's  mother  and  the  other  in  a  mother's  sister  ;  but 
as  both  of  these  ended  fatally,  the  disease  was  probably  really 
malignant.  This  experience  is  by  no  means  exceptional,  for  I 
have  found  equally  few  instances  of  non-malignant  neoplasms 
in  the  relatives  of  patients  with  cancer  of  other  parts  of  the 
body,  although  I  inquired  just  as  carefully  after  the  former  as 
after  the  latter.^''^ 

(/;)  Hereditary  proclivities  correlated  ivith  cancer. 

The  remarks  I  have  to  make  on  this  subject  are  based  upon 
the  subjoined  analysis  of  the  family  history  of  134  women  with 
cancer  of  the  breast.     This  analysis  shows  : — 

(i)  That  pulmonary  tubercle  is  by  far  the  most  prevalent 
disease  among  the  relatives  of  cancerous  persons.  Such  a  result 
is  only  what  might  have  been  expected  a  priori.,  considering  the 
frequency  of  tubercular  disease  in  the  community  at  large;  but 


"  For  some  further  remarks  on  this  subject  the  reader  is  referred  to  chap,  xviii. 


FAMILY    HISTORY.  27 1 

a  great  mistake  has  been  made  in  taking  it  for  granted,  on  this 
account,  that  the  relatives  of  cancerous  persons  have  no  special 
proclivity  to  tubercle.  On  the  contrary,  as  I  shall  proceed  to 
show,  such  persons  are  very  much  more  prone  to  it  than  the 
rest  of  the  community;  indeed,  their  liability  to  phthisis  is  so 
considerable,  as  even  to  equal  that  of  the  phthisical  themselves. 
No  statistics  show  a  greater  amount  of  heredity  in  phthisis 
than  Dr.  R.  Thompson's,*^  because  he  has  included  in  his  list 
only  those  cases  in  which  the  family  history  had  been  very  com- 
pleitely  recorded.  He  obtained  history  of  heredity  in  44  per 
cent,  of  5,000  consecutive  phthisical  cases — 58  per  cent,  in 
females  and  36  per  cent,  in  males.  Now,  my  analysis  of  the 
family  history  of  134  women  with  mammary  cancer  shows  a 
history  of  phthisis  in  55  per  cent.,  which  is  almost  as  high  a 
proportion  as  Thompson's.  The  amount  of  hereditary  phthisis 
among  the  rest  of  the  community  is  very  much  less  than  this ; 
it  has  been  estimated  by  Dovey,*''  from  analysis  of  the  family  his- 
tory of  409  non-consumptive  life-policy  holders,  at  iO'8  per  cent. 
Nothing,  therefore,  can  be  plainer  than  that  the  relatives  of  can- 
cerous patients  are  very  much  more  prone  to  tubercle  than  the 
rest  of  the  community.  This  is  borne  out  by  the  results  dedu- 
cible  from  my  analysis  of  the  causes  of  death  of  the  brothers  and 
sisters  of  patients  with  mammary  cancer  in  88  families.  These 
averaged  8'8  members  each,  in  all  774  individuals.  Now,  one 
or  more  deaths  from  phthisis  took  place  in  40  of  these  families. 
Supposing  only  a  single  death  to  have  occurred  in  each  of  them, 
this  would  be  equivalent  to  one  death  from  phthisis  in  19  mem- 
bers, whereas  the  mortality  from  phthisis  in  the  general  popu- 
lation in  1885  amounted  to  i  in  570.  Similarly  among  83  fathers 
of  mammary  cancer  patients,  who  had  died  of  various  causes,  the 
mortality  from  phthisis  was  22,  or  i  in  3'8  ;  among  71  mothers, 
it  was  18,  or  i  in  3*9,  or  among  these  154  parents,  it  was  40,  or  i 
in  3'8  ;  whereas  the  ratio  of  deaths  from   phthisis  to  the  total 


"  Family  Phthisis,"  London,  1885. 
Quoted  by  Thompson,  Op.  cit.,  p.  16. 


272         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

mortality  in  the  general  community,  in  1885,  amounted  only  to 
I  in  1 1,  Long  study  of  the  family  history  of  cancer  patients  has 
convinced  me,  that  a  large  proportion  of  the  latter  are  the  sur- 
viving members  of  tubercular  families ;  and  the  facts  just  cited 
confirm  this  belief.  On  the  same  ground  I  conclude,  that  no 
hereditary  condition  is  more  favourable  to  the  development  of 
cancer  than  that  which  predisposes  to  and  accompanies  tubercle. 

The  much  greater  frequency  with  which  obsolete  tubercle 
is  found  in  association  with  cancer  than  with  most  other  dis- 
eases, is  also  an  argument  in  favour  of  this  view.  Thus,  of  136 
consecutive  necropsies  on  women  under  my  observation,  who 
died  of  cancer  (uterus  79,  breast  44,  rectum  i  3),  obsolete  pul- 
monary tubercle  was  found  in  17,  or  in  I2'5  per  cent  ;'*^  whereas 
of  16,562  consecutive  necropsies,  tabulated  by  Heitler,'*"  on  per- 
sons who  had  died  of  various  causes — which  included  but  no 
cases  of  cancer  (o'6  per  cent.) — obsolete  tubercle  was  met  with 
only  in  789  cases,  or  in  4*7  per  cent. 

Although  cancer  and  tubercle  are  thus  intimately  connected, 
it  is  very  rare  to  find  both  diseases  in  active  progress  in  the 
same  individual.  I  have  met  with  this  conjunction  only  twice 
out  of  136  cancer  necropsies.'''^  In  the  other  cases  it  was  evident 
that  arrest  of  the  tubercular  disease  had  long  preceded  the  out- 
break of  cancer.  The  combination  of  both  phthisis  and  cancer 
in  the  same  family's  history  was  noted  by  me  in  18  out  of  134 
cases,  or  in  I3"4  per  cent.  Another  consideration  which  accords 
with  the  foregoing  views  is,  that  in  families  where  cancer  prevails, 
according  to  Moore,^'  the  elder  members  are  more  prone  to  be- 
come cancerous  than  the  younger  ones,  the  first-born  being  the 
most  liable.  Whereas,  with  regard  to  phthisis,  it  has  been 
shown  by  Thompson  that  the  younger  members  are  the  more 


"  Of  130  breast  cancer  paliLMits,  five  were  awnrc  of  havin;^  had  previous  phthisical 
disease,  or  3  "8  per  cent. 

«'  Wiener  Klinik,   1879,  S.  269. 

=**  Of  173  cancer  necropsies  analysed  by  Sibley,  in  11  active  tiil)ercuIosis  was 
present,  Ahd.  Chir.   Trans.,  vol.  xlii. 

■'  "  .Antecedents  of  Cancer,"  p.  35. 


FAMILY    HISTORY.  273 

liable — the  greatest  liability  being  with  the  last  born.  I  have 
dwelt  at  some  length  on  this  subject,  because  it  appears  to  me 
to  have  an  important  bearing  on  the  aetiology  of  cancer;  and 
so  far  as  I  know,  it  has  never  before  been  set  forth  in  its  true 
light. 

(2)  If  similar  investigations  were  set  on  foot  with  regard  to 
other  diseases,  I  believe  it  would  be  found  that  the  tubercular 
predisposition  gives  proclivity  to  many  of  them,  as,  for  instance, 
it  certainly  does  to  insanity.  Thus  Clouston'^^  found  tubercular 
deposits  twice  as  often  in  the  bodies  of  those  who  died  insane 
as  in  the  bodies  of  those  who  died  sane ;  and  he  has  proved  that 
hereditary  predisposition  to  insanity  is  much  greater  among  the 
tubercular  than  among  the  non-tubercular.  In  this  connection 
it  is  worthy  of  note  that  the  relatives  of  cancerous  persons  are 
more  prone  to  insanity  than  are  the  relatives  of  the  non-can- 
cerous ;  at  least  this  is  the  conclusion  I  draw  from  the  fact  that 
5 1  female  cancer  patients  under  my  observation  gave  a  family 
history  of  insanity  in  7  cases,  or  in  137  per  cent. ;  whereas  29 
women  with  non-malignant  neoplasms  knew  of  insane  relatives 
only  in  3  instances,  or  in  I0"4  per  cent.  ;  and  the  latter  is  pro- 
bably a  higher  percentage  than  would  be  met  with  in  the  general 
community. 

The  liability  of  insane  persons  and  idiots  to  cancer  is  de- 
cidedly below  the  average.^^  Of  5,373  lunatics  who  died  while 
under  treatment  at  the  Hanwell  and  Hitchen  Asylums  (1870-91) 
only  125  died  of  cancer,  or  i  in  39.  Of  2,741  females,  loi 
died  cancerous,  or  i  in  27,  and  of  2,623  males  34,  or  i  in  yj. 

(3)  Many  authors  regard  apoplexy  as  a  manifestation  of  the 
same  neurotic  disposition,  of  which  insanity  is  also  an  outcome ; 
and  my  analysis  shows  that  this  disease  is  unduly  prevalent 
among  the  relatives  of  cancerous  persons.  Thus  of  154  parents 
of  women  with  mammary  cancer,  who  died  of  various  causes,  17 
died  of  apoplexy,  or  one  in  nine  ;    whereas  the  ratio  of  deaths 


^-  Cited  by  Maudsley,  "  Pathology  of  Mind,"  p.  112. 
"  Snow,  Journal  Mental  Sci.,  Oct.,  1891,  p.  548. 


2  74         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

from  apoplexy  to  the  total  mortality  of  the  general  population 
in  1884,  was  only  one  to  36.  Similar  undue  frequency  of  this 
disease  is  noticeable  among  the  brothers  and  sisters  of  these 
cancer  patients  ;  for,  while  one  in  258  of  the  latter  died  of 
apoplexy,  the  mortality  from  it  in  the  general  community 
in  1884  amounted  only  to  one  in  1,841. 

(4)  There  is  reason  to  believe  that  the  members  of  cancer 
families  are  also  unduly  prone  to  artJiritic  manifestations,  as 
was  the  case,  for  instance,  in  the  Bonaparte  family,  Prince  Pierre 
having  died  of  heart  disease,  consequent  on  rheumatic  fever,  and 
Napoleon  III.  of  stone  in  the  bladder.^*  My  analysis  shows 
twelve  deaths  from  heart  disease  among  154  parents  of  breast 
cancer  patients,  or  one  in  I2"8  ;  whereas  in  the  general  com- 
munity the  corresponding  ratio  in  1884  was  one  to  79.  From 
rheumatic  fever  my  analysis  shows  one  death  in  154  parents; 
whereas  the  rate  for  the  community  at  large,  in  1884,  was  one  in 
195.  Of  160  cases  analysed  by  Nunn,  gout  and  rheumatism 
were  traced  in  15.  There  is  also  evidence  of  a  considerable 
amount  of  heart  disease  and  rheumatic  fever  among  the 
patient's  brothers  and  sisters;  and  of  130  breast  cancer 
patients  under  my  observation,  11  had  previously  suffered 
from  rheumatic  fever  and  6  from  rheumatism. 

There  still  remain  to  be  considered  two  other  proclivities  to 
which  the  members  of  cancer  families  are  remarkably  subject, 
viz.,  longevity  and  great  reproductive  fecundity. 

(5)  The  evidence  furnished  by  my  analysis  as  to  the  lojtgevity 
of  the  parents  of  cancer  patients  is  of  the  most  striking  and  con- 
clusive kind.  To  prove  this  it  will  suffice  to  mention  only  a  few 
of  the  leading  facts. 

Of  112  dead  fathers  14  attained  the  age  of  80,  which  is 
equivalent  to  1,250  per  10,000,  whereas  in  the  general  population 
only  463  males  live  to  this  age  out  of  10,000. 

"  Two  other  members  of  this  family — King  Jerome  and  his  son,  Prince  Napoleon 
— were  subject  to  diabetes.  This — which  is  a  rare  disease —is  associated  with  in- 
sanity and  tubercle  :  my  analysis  shows  an  undue  amount  of  it  (two  deaths  in  154) 
among  the  relatives  of  cancer  patients. 


FAMILY    HISTORY.  275 

Of  103  dead  mothers  17  attained  the  age  of  80,  which 
is  equivalent  to  1,650  per  10,000,  whereas  in  the  general  popu- 
lation only  682  females  live  to  this  age  out  of  10,000. 

Of  these  215  dead  parents  two  attained  the  age  of  95,  which 
is  equivalent  to  93  per  10,000,  whereas  in  the  general  population 
only  21  per  10,000  live  to  this  age. 

At  first  sight  this  result  appears  to  be  in  contradiction  with 
the  conclusion  previously  arrived  at,  that  the  relatives  of  cancer 
patients  are  especially  liable  to  pulmonary  tubercle,  but  it  must 
be  borne  in  mind  that  these  cancer  families  are  generally  ex- 
ceedingly numerous.  Striking  confirmatory  evidence  is  furnished 
by  inquiring  into  the  family  history  of  centenarians  and  aged 
persons,  whence  it  appears  that  a  large  proportion  of  these — 20 
per  cent,  in  the  case  of  females — are  the  surviving  members  of 
phthisical  families.  It  is  evident,  therefore,  that  the  constitu- 
tional peculiarity,  which  is  associated  with  tubercle,  is  by  no 
means  incompatible  with  longevity.^^ 

(6)  Equally  conclusive  is  the  evidence  as  to  the  great 
fecundity  of  cancer  families. 

Thus,  no  of  these  families  included  in  my  analysis,  averaged 
8*8  members  in  each  family,  or  968  members  in  all  ;  whereas, 
according  to  Farr,^^  in  the  general  community  the  average 
number  to  a  family  is  4'6,  so  that  an  equal  number  of  families 
would  include  only  506  members. 

The  foregoing  conclusions,  although  based  solely  upon  facts 
derived  from  the  study  of  the  family  history  of  women  with 
cancer  of  the  breast,  are  nevertheless,  as  I  have  ascertained, 
equally  valid  for  cancer  of  all  parts  of  the  body. 

Analysis  of  the  family  history  0/12,4  wo7nen  with  cancer  of  the 

breast  I — 

The  Fathers. — Of  129  cases  in  which  inquiries  were  made  with  regard  to 
the  fathers,  in  117  they  were  dead,  and  in  twelve  still  alive.  The  causes  of 
death   were  known  in  83  cases,  as  follows  : — Phthisis  in  22  cases  ;    heart 

"  "  Old    age    and    the    changes    incidenlal    to    it,"     British    Medical  yoiirjial, 
May  9,  1885. 

"  Vital  Statistics,"  1885,  p.  98. 


58     t( 


276         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

disease,  1 1  ;  apoplexy,  9  ;  bronchitis,  8  ;  cancer,  5  ;  dropsy,  5  ;  old  age,  4  ; 
accident,  3  ;  cholera,  2  ;  strangulated  hernia,  2  ;  renal  disease,  diabetes, 
fever,  diarrhoea,  white  swelling  of  knee,  sunstroke,  erysipelas,  typhoid  fever, 
ulcer  of  leg  (hcemorrhage),  suicide  (alchoholism),  insanity  and  cerebral 
softening,  each  one  case. 

Of  those  who  had  died  of  phthisis^  in  7  cases  other  members  of  the 
family  had  also  died  of  this  disease.  Twelve  of  these  fathers  who  had  died 
of  causes  other  than  phthisis  were,  however,  of  phthisical  families.  Thus  of 
these  83  fathers,  34  (40-9  per  cent.)  were  of  phthisical  families. 

There  were  among  them  5  deaths  from  cancer  (6  per  cent.)  ;  the 
localities  affected  being  the  breast,  lip,  hand,  liver,  and  "internal."  Seven 
fathers  who  had  died  of  causes  other  than  cancer  were,  however,  of  can- 
cerous families. 

The  relatives  thus  affected  and  the  seats  of  the  disease  were  as  follows  : — 

(i)  Father  died,  aged  57,  of  heart  disease  :  his  father  died,  aged  60,  of 
cancer  of  the  oesophagus  ;  and  his  mother's  first  cousin  died  of  cancer  of 
the  oesophagus. 

(2)  Father  died,  aged  55,  of  phthisis;  his  mother  died  of  cancer  of  the 
breast. 

(3)  Father  died,  aged  69,  insane  ;  his  sister  died  of  cancer  of  the  breast. 

(4)  Father  died,  aged  64,  of  apoplexy  ;  his  father  died,  aged  76,  of  cancer 
of  the  nose. 

(5)  Father  died,  aged  80,  of  apoplexy  ;  his  sister  died,  aged  75,  of  cancer 
of  the  scalp. 

(6)  Father  died,  aged  62,  of  apoplexy  ;  his  sister  died  of  internal  cancer. 

(7)  Father  died,  aged  73,  of  heart  disease  :  his  mother  died  of  cancer  of 
the  breast. 

Thus  of  these  83  fathers,  12  (14*4  per  cent.)  were  of  cancerous  families. 

The  average  as;e  of  the  fathers  at  deaths  in  112  cases,  was  62'4  years  ; 
the  oldest  96  (14  having  attained  or  exceeded  80  years),  the  youngest  30. 

Of  the  12  fathers  still  alive^  two  were  subject  to  heart  disease  and  dropsy, 
and  one  to  chronic  rheumatism,  one  to  chronic  bronchitis,  and  one  had  a 
lipoma  of  the  back.     The  others  were  in  good  health. 

The  average  age  (in  the  nine  cases  in  which  it  is  stated)  was  72*4  years  ; 
the  oldest  83  (two  attained  or  exceeded  80),  the  youngest  60. 

Two  of  these  12  fathers  were  oi  phthisical  families,  each  having  lost  a 
sister  from  this  disease,  as  well  as  from  cancer. 

Four  of  them  were  of  ca?tcerous  families,  the  relatives  affected  and  the 
seats  of  the  disease  being  as  follows  : — 

(i)  Sister  died,  aged  40,  of  cancer  of  the  mouth,  and  another  sister  died, 
at  about  the  same  age,  of  cancer  of  the  face. 

(2 — 4)  In  two  cases  a  sister  died  of  cancer  of  the  breast  ;  and  in  one 
case,  a  sister  was  suffering  from  cancer  of  the  breast. 

The  Mothers. — Of  125  cases  in  which  inquiries  were  made  with  regard 
to  the  mothers,  in  105  they  were  dead,  and  in  20  still  alive.  The  causes  of 
death  were  known  in  71  cases,  as  follows  : — Phthisis,  18  cases  ;  apoplexy, 
8  ;  dropsy,  8  ;  cancer,  7  ;  bronchitis,  6  ;  liver  disease,  3  ;  pneumonia,  3  ; 
cholera,  3  ;   childbed,    2  ;  old  age,  2.     Abdominal    tumour,    chest   disease, 


FAMILY    HISTORY.  277 

rheumatic  fever,  diabetes,  jaundice,  peritonitis,  quinsy,  typhoid  fever,  heart 
disease,  strangulated  hernia,  and  sudden  death  in  bed,  each  one  case. 

Of  those  who  had  died  of  phthisis,  in  three  cases  other  members  of  their 
famihes  had  also  died  of  this  disease.  Six  of  these  mothers,  who  had  died 
of  causes  other  than  phthisis,  were,  however,  of  phthisical  families.  Thus,  of 
these  71  mothers  24  (33'9  per  cent.)  were  of  phthisical  families. 

There  were  among  them  seven  deaths  from  cancer  (9"8  per  cent.),  the 
localities  affected  being  the  uterus  (2),  internal  (2),  breast,  stomach,  and 
tongue,  each  one.  Six  of  these  mothers  who  had  died  of  causes  other  than 
cancer  were,  however,  of  cancerous  families.  The  relatives  thus  affected, 
and  the  seats  of  the  disease  were  as  follows  :  — 

(i)  Mother  died,  aged  70,  of  phthisis  ;  a  relative  of  hers  died  of  cancer 
of  breast. 

(2)  Mother  died,  aged  82,  suddenly  in  bed  ;  her  sister  died  of  cancer  of 
breast. 

(3)  Mother  died,  aged  68,  of  apoplexy  ;  her  sister  died  of  cancer  of 
tongue. 

(4)  Mother  died,  aged  70,  of  apoplexy  ;  her  cousin  died  of  cancer — 
locality  not  stated. 

(5)  Mother  died,  aged  66,  of  bronchitis  ;  her  mother  died  of  cancer  of 
uterus. 

(6)  Mother  died  of  phthisis  ;  her  sister  died  of  cancer  of  breast. 

Thus,  of  these  71  mothers,  13  (i8'3  per  cent.)  were  of  cancerous  families. 
The  average  age  of  the  mothers  at  death,  in  103  cases,  was  62  years  ;  the 
oldest  within  a  few  months  of  100  (17  having  attained  or  exceeded  80  years), 
the  youngest  25. 

Of  the  20  mothers  still  alive,  all  save  2  (bronchitis  i,  and  spinal  disease 
i),  were  well.  Their  average  age  (in  16  cases)  amounted  to  71  "5  years  ;  the 
oldest  84  (3  had  attained  or  exceeded  80),  the  youngest  60.  Of  these  20 
mothers  5  were  of  phthisical  and  2  of  cancerous  families. 

Co7tsanguinity  in  the  Parents. — As  to  this,  inquiries  were  made  in  33 
cases,  with  the  result  that  in  2  instances  the  parents  were  blood  relations. 

In  one  case  they  were  first  cousins  ;  the  father  died  of  heart  disease, 
aged  66,  and  his  father  died  insane  ;  the  mother  died,  aged  78,  of  dropsy. 
There  were  5  children  of  the  marriage  ;  2  died  in  infancy,  and  2  sisters  were 
still  alive  and  well.  There  was  no  history  of  cancer,  tumour,  or  phthisis  in 
either  family.  In  the  other  case  the  parents  were  third  or  fourth  cousins. 
The  father  died,  aged  55,  of  phthisis,  and  his  mother  died  of  cancer  of  the 
breast.     The  mother  died,  aged  80,  of  old  age. 

The  Paiieftfs  Brothers  and  Sisters. — In  88  families  the  following  causes 
of  death  were  noted  among  the  adults  : — Phthisis  (one  or  more  deaths)  in  40 
famihes  ;  heart  disease,  8  ;  dropsy,  6  ;  cancer,  5  ;  childbed,  5  ;  rheumatic 
fever,  3  ;  apoplexy,  3  ;  bronchitis,  3  ;  typhoid  fever,  3  ;  traumatism,  3 ;  fever, 
2  ;  smallpox,  2  ;  cholera,  2  ;  peritonitis,  2  ;  and  hepatic  disease,  2  families. 
Cerebral  disease,  scarlet  fever,  yellow  fever,  insanity,  delirium  tremens, 
tubercular  abscesses,  pleurisy,  diabetes,  pneumonia,  tuberculosis  of  the 
bowels,  pyaemia,  jaundice,  tubercular  arthritis,  and  strangulated  hernia,  each 
one  case. 


278         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

Of  the  families  in  which  phthisis  prevailed,  in  15  more  than  a  single 
member  had  died  of  this  disease. 

Of  1 10  families,  the  number  of  members  in  each  family  was  noted,  with 
the  result  that  the  smallest  family  consisted  of  one  (two  instances),  the 
largest  of  19  (two  of  17),  the  average  of  S'S 

The  Occurrence  of  Phthisis. — Of  134  families,  among  the  adults,  one  or 
more  relatives  had  died  of  or  were  subject  to  phthisis,  in  74  or  55"2  per  cent. 

In  2)7  of  these  families  more  than  a  single  individual  had  died  of  this 
disease. 

The  relatives  thus  affected  may  be  conveniently  arranged  as  follows  : — 


Both  paternal  grandparents  in 

Paternal  grandmother  in 

Both  parents     ... 

Fathers... 

Father's  brothers  and  sisters... 

Mothers 

Mother's  brothers  and  sisters 
Patient's  brothers  and  sisters 


I  family. 


I 

5 

16 
18 

13 

8 

37 


The  Combination  of  Phthisis  atid  Cajtcer. — Of   134  cases, 


n   18  there 


was  history  of  both  phthisis  and  cancer  in  the  same  family.     Thus  : — 

! Father's  side  nine  families. 
Mother's  side  in  one  family. 
Patient's  brothers  and  sisters  in  four  families. 
5 Father's  side  in  two  families. 
Mother's  side  in  twelve  families. 
Patient's  brothers  and  sisters  in  two  families. 

r>„  J  uuti,    •  (Father's  side  in  three  families. 

Cancer  and  Phthisis  on     ii\/r  »u    )       j    ■     ^x.        c      ■■>■ 

(Mother's  side  in  three  families. 

The  Occurrence  of  Insanity. — As  to  this  enquiries  were  made  in  18 
families  :  in  three  there  was  history  of  insanity,  the  patient's  paternal  grand- 
father, father,  and  sister  being  the  relatives  respectively  affected. 


§    V . The  Prevalence  of  Cancer  and  its  Increase. 

In  the  course  of  organic  evolution  some  types  of  disease — 
like  species — have  diminished  and  become  extinct;  while  others 
have  increased  and  become  more  prevalent.  In  comparatively 
recent  times,  plague,  typhus,  leprosy,  ague,  and  dysentery  have 
almost  or  quite  disappeared  from  this  country,  and  smallpox  has 
greatly  diminished,  while  phthisis  and  other  forms  of  tubercular 
disease  are  now  decidedly  on  the  wane.  On  the  other  hand 
cancer — a  disease   known   to  have  existed   in  its  present  form 


PREVALENCE    OF    CANCER.  279 

from  the  most  remote  times  of  which  we  have  any  record — has 
steadily  increased  during  the  last  half  century,  and  is  still  in- 
creasing, and  this  in  spite  of  diminution  in  the  general  death-rate. 
Insanity  also  is  on  the  increase.^^ 

Prior  to  1837,  when  the  Registration  Act  came  into  operation, 
we  have  no  reliable  information  as  to  the  prevalence  of  cancer. 
In  1 840,  it  caused  2,786  deaths,  the  proportion  being  one  in  5,646 
of  the  total  population,  one  in  129  of  the  total  mortality,  or  177 
per  million  living;  in  1890,  the  deaths  due  to  it  numbered 
19,433,  being  o"^  '^^  1,480  of  the  total  population,  one  in  twenty- 
eight  of  total  mortality,  or  626  per  million  living.  Thus  the 
proportionate  mortality  from  cancer  now  is  about  four  times 
greater  than  it  was  half  a  century  ago.  Among  women  of 
35  years  of  age  and  upwards,  it  has  increased  from  one  in 
ninety-one  for  the  decennial  period,  1851-60,  to  one  in  twelve 
for  the  period  1887 — 89.  From  the  extent  of  the  mortality 
and  the  average  duration  of  the  disease,^^  there  cannot  be 
fewer  than  40,000  persons  now  suffering  from  cancer  in  Eng- 
land and  Wales  ;  whereas,  in  1840,  the  number  was  only  about 
5,500. 

In  this  respect  its  position  is  unique;  no  other  disease  can 
show  anything  like  such  an  immense  increase.  It  seems  certain, 
that  if  unchecked,  cancer  will  ere  long  become  one  of  the  com- 
monest diseases  of  modern  communities. 

In  illustration  of  this  subject  I  have  compiled  the  following 
table,  which  shows  the  increase  in  England  and  Wales  since 
1840  : — 


■"•'  In  187 1  the  proportion  of  insane  persons  in  England  and  Wales  was  3,034  per 
million  living,  or  i  in  329  ;  in  1881  it  had  increased  to  3,252  per  million,  or  i  in  307  ; 
and  in  1891  the  numbers  were  3,360  per  million,  or  i  in  297.  Thus  the  increase 
during  1871-81  was  7*04  per  cent.,  and  during  1881-91,  3*23  per  cent.  Most  of  the 
increase  has  taken  place  in  persons  above  45  years  of  age,  and  females  have  been 
affected  more  than  males.  Suicides  have  also  increased  from  65' 2  per  million  living 
in  1861-65,  to  79"4  in  1886-90. 

^'  Taken  at  the  low  estimate  of  two  years. 


28o 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


Table  Showing  the  Prevalence  of  Cancer  and  its   Increase  in 
England  and  Wales. 


Year. 

Total 
Population. 

Total 
Deaths. 

Cancer 
Deaths. 

U  4J  C 

^  n  ° 

Proportion  to 
Population. 

Proportion 
to  Total 
Deaths. 

1840 

15,730,813 

359,687 

2,786 

177 

I  to  5,646 

I  to  129 

1S50 

17,773,324 

368,995 

4,966 

279 

I  „  3,579 

I  „   74 

1855 

18,829,000 

426,646 

6,016 

319 

I  „  3,129 

I  „   70 

i860 

19,902,713 

422,721 

6,827 

343 

I  „  2,915 

I  „   62 

1865 

21,145,151 

490,909 

7,922 

372 

I  „  2,670 

I  „   62 

1870 

22,501,316 

515,329 

9,530 

424 

I  „  2,361 

I  V  54 

1875 

24,045,385 

546,453 

11,336 

471 

I  „  2,121 

I  „  48 

1880 

25,714,288 

528,624 

13,210 

502 

I  „  1,946 

I  „  40 

1881 

25,974,439 

491,937 

13,542 

520 

I  „  1,918 

I  „  36 

1882 

26,413,861 

516,654 

14,057 

532 

I  „  1,879 

I  „  36 

1883 

26,770,744 

522,997 

14,614 

546 

I  „  1,763 

I  „  35 

1884 

27,132,449 

530,828 

15,192 

559 

I  „  1,786 

I  „  35 

1885 

27,499,041 

522,750 

15,560 

566 

I  „  1,767 

I  „  33 

1886 

27,870,586 

537,276 

16,243 

583 

I  „  1,715 

I  „  33 

1887 

28,247,151 

530,758 

17,113 

606 

I  „  1,650 

I  „  31 

1888 

28,628,804 

510,971 

17,506 

610 

I  „  1,635 

I  „  29 

i889'^"-' 

29,015,613 

518,353 

18,654 

643 

I  „  1,555 

I  „  27 

1 890^0 

28,762,287 

562,248 

19,433 

676 

I  „  1,480 

I  „  28 

1891 

29,081,047 

587,925 

20,  II 7 

692 

I  „  1,445 

I  „  29 

Mere  increase  of  population  will  not  account  for  this  con- 
tinuously progressive  augmentation  of  the  cancer  death-rate,  as 


*"  Estimated  on  the  1881  Census. 
'"  Estimated  on  the  1891  Census. 


PREVALENCE    OF    CANCER. 


281 


is  evident  from  the  fact  that  its  rate  of  increase  has  propor- 
tionally been  much  in  excess  of  this  ;  and  there  is  far  too  much 
uniformity  in  the  variations  of  the  increments  of  increase  in  the 
long  succession  of  years,  to  warrant  its  being  ascribed  to  im- 
proved diagnosis  or  other  casual  error.  Moreover,  the  increase 
has  not  been  confined  to  one  or  a  few  parts  of  the  body  ;  but  it 
has  involved  them  all — on  the  whole  without  any  considerable 
disturbance  of  the  normal  proportionate  localisation  ratios,^^ 

Again,  as  I  have  previously  indicated,^^  the  increase  has 
been  diffused  over  the  whole  country,  instead  of  being  limited  to 
certain  areas  only ;  so  that  those  parts  that  formerly  had  the 
highest,  lowest,  and  average  cancer  death  rates,  still  preserve 
their  distinction  in  these  respects,  although  the  cancer  mortality 
has  everywhere  augmented.  There  can,  therefore,  be  no  doubt 
as  to  its  reality,^* 

The  returns  for  Scotland  exhibit  a  similar  state  of  things,  as 
is  shown  by  the  following  figures  : — 


1861  to  65 
1866  „  -JO 

'871  „  75 
1876  „  80 
1881  „  8q 


Cancer  death  rate  per 
million  living. 


404 
428 
468 
504 
540 


•*'  The  Registrar-General's  report  for  England,  based  on  the  mortality  returns  for 
the  years  1868  and  1888,  show  that  all  the  seats  of  the  disease  participated  in  the 
increase,  although  it  affected  the  commoner  ones  to  a  less  degree  than  the  others. 
It  was  least  in  the  uterus,  female  breast  and  stomach  ;  and  in  males,  in  the  tongue 
and  mouth,  face,  penis,  &c. ;  and  greatest — for  both  sexes — in  the  intestines,  liver, 
rectum,  oesophagus,  bladder,  &c.  The  Registrar-General's  report  for  Ireland  for  the 
five  years  1887-91,  also  show  that  all  the  seats  of  the  disease  participated  in  the 
increase,  and  that  without  any  considerable  disturbance  of  the  normal  localisation 
ratios.  For  further  details  vide  a  communication  by  the  author  in  the  British  Med. 
Journ.,  vol.  i. ,  1893,  P-  547- 

"2 §111.,  pp.  254-6. 

"'  In  a  recent  publication  {Proceedings  of  the  Royal  Society,  No.  327,  vol.  liv.) 
Dr.  Newsholme  has  maintained  the  contrary  thesis,  attempting  to  account  for  the 
increase  as  the  result  of  improved  diagnosis.  For  his  discussion  of  this  question  with 
the  author  vide  Brit.  Med.  fourn.,  Dec.  30,  1893,  and  early  numbers  of  1S94. 


2»2 


GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


Year. 

Total  Popu- 
lation. 

Total 
Deaths. 

Cancer 
Deaths. 

Q    J;.= 

Proportion  to 
Population. 

Proportion 

to 

Total  Deaths. 

1884 

3,829,772 

75,i68 

2,110 

550 

I  to  1,815 

I  to  35 

1885 

3,859,234 

74,607 

2,173 

560 

I    „    1,776 

I    „   34 

1886 

3,888,922 

73,640 

2,313 

590 

I    „    1,681 

I    „    31 

1887 

3,918,841 

74,546 

2,373 

600 

I    „    1,652 

I    „    31 

1888 

3,948,989 

71,174 

2,450 

610 

I    „    1,612 

I    „    29 

1889 

3,979,406   • 

73,238 

2,643 

670 

I    „    1,505 

I    „    27 

1890 

4,003,132 

79,004 

2,428 

610 

I    „    1,643 

I    1,    32 

In  most  civilised  countries  where  statistical  records  have  been 
kept  similar  increases  have  been  observed.  In  Norway  the 
cancer  deaths  increased  from  32  per  1,000  of  the  total  mortality 
in  1877  to  60  per  1,000  in  1886-87.  In  the  Netherlands  the 
increase  was  from  4-9  per  10,000  living  in  1867-79  to  65  in 
1884-88,  and  in  Prussia  from  3-1  in  1881  to  3-8  in  1887.  Brussels 
is  credited  with  an  increase  from  3*9  in  1864-73  ^o  4'2  in  1874-78  ; 
and  in  New  York  the  rise  was  from  4  in  1875  to  5-3  in  1885. 
In  Australia  and  New  Zealand  similar  phenomena  have  been 
recorded ;  thus  the  Victoria  cancer  mortality,  which  was  37  in 
1871-80,  rose  to  47  in  1882-86,  and  in  New  Zealand  the  rise 
was  from  2-6  in  1879  to  4*3  in  1888. 

In  all  the  above  instances  the  augmented  cancer  mortality 
has  coincided  with  progressive  population,  increased  national 
wealth,  and  marked  improvement  in  the  general  well-being.  It 
seems  to  me  impossible  to  regard  these  coincidences  otherwise 
than  as  the  result  of  cause  and  effect. 

It  accords  with  this  view  that  in  Ireland — where  less  favour- 
able material  conditions  have  prevailed — the  cancer  death-rate 
has  been  much  lower  than  in  either  of  the  sister  countries  ;  and 
for  many  years  it  has  shown  no  such  marked  increase  as  in  the 
latter,  as  is  shown  by  the  subjoined  figures  : — 


PREVALENCE    OF    CANCER. 


283 


1870 

1873 
1875 

1877 
1878 

1879 


Per  Million  Living. 

330 
330 
350 
360 

340 
340 


Year. 

Total 
Population. 

Total 
Deaths. 

Cancer 
Deaths. 

"Be 

C  rt  0 

6^~ 

Proportion 

to 
Population. 

Proportion 

to 

Total 

Deaths. 

1881 

5,144,983 

90,035 

1,909 

371 

I  to  2,695 

I  in  47 

1882 

5,097,853 

88,500 

1,882 

369 

I    „    2,708 

I  „  47 

1883 

5,015,281 

96,228 

1,995 

398 

I    „    2,514 

I  „  48 

1884 

4,962,693 

87,154 

1,947 

392 

I    „    2,548 

I  „  44 

1885 

4,924,342 

90,712 

1,925 

391 

I    „    2,558 

I  „  47 

1886 

4,889,498 

87,292 

2,029 

415 

I    „    2,409 

I  „  43 

1887 

4,837,313 

88,585 

2,067 

427 

I    „    2,340 

I  „  42 

1888 

4,777,534 

85,892 

2,003 

419 

I    „    2,358 

I  „  42 

1889 

4,730,566 

82,908 

2,134 

451 

I    „   2,212 

I  „  38 

1890 

4,688,462 

85,850 

2,145 

458 

I    „   2,185 

I  „  40 

A  curious  fact  about  the  increasing  cancer  mortality  of  Great 
Britain  is,  that  it  has  affected  males  to  a  much  greater  extent 
than  females.  Thus,  from  1851  to  1890  the  increase  for  males 
was  167  per  cent. ;  whereas  for  females  it  only  amounted  to  91 
per  cent.     The  following  figures  illustrate  this  more  fully  : — 


Male  Cancer  Death- 

Female 

Cancer  Death- 

Rate  per  Million 

Rate 

per  Million 

Living. 

Living. 

Ratios. 

1 85 1  to  i860 

...       195 

434         1 

to  2-2 

I86I  „  1870 

...       244 

523         1 

.,    2-1 

I87I  „  1880 

...       315 

622         

„  1-9 

1885 

...       411 

713         

I  „  17 

T890 

...       512 

830        

r  „  v6 

284         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

It  seems  to  me  probable  that  this  undue  incidence  of  the  in- 
creasing cancer  mortality  on  males,  may  be  ascribed  to  the  fact 
that  of  late,  as  the  result  of  urbanisation,  the  conditions  of  life 
for  men  have  come  to  resemble  more  closely  those  for  women 
than  heretofore.  Excess  of  food,  with  want  of  proper  exercise, 
and  changed  surroundings,  are,  I  think,  its  chief  causative  agents. 
In  this  connection  the  remarkable  sex  distribution  of  cancer  in 
New  Zealand,  to  which  I  have  previously  referred,  should  be  borne 
in  mind.  Here  more  men  are  affected  than  women  ;  and  this  is 
attributed  locally  chiefly  to  their  gluttonous  habits  with  regard 
to  meat  eating.  It  is  worthy  of  note  that  for  both  sexes  the 
percentage  of  cancer  deaths  above  55  is  greater  than  it  used  to 
be ;  and  a  far  larger  proportion  of  the  male  deaths  occur  after 
65  than  of  the  female  deaths. 

The  attempt  to  explain  the  increasing  cancer  mortality  as 
due  to  the  average  age  of  the  population  having  advanced  and 
the  consequent  liability  of  greater  numbers,  will  not  bear  critical 
examination  ;  for  the  saving  of  life  in  modern  times  has  been 
mainly  confined  to  early  years.  The  death  rates  of  males  over 
35,  and  of  females  over  45,  have  actually  increased;  while  the 
numbers  that  attain  old  age  have  decreased.^^  This  increased 
mortality  at  post-meridian  ages  is  no  doubt  largely  due  to  the 
survival  in  augmented  numbers  of  weakly  lives  artificially  pro- 
longed by  improved  conditions  of  existence  ;  but,  according  to 
Newsholme,  not  more  than  ^V  of  the  increased  cancer  mortality 
can  be  thus  accounted  for.  Besides,  it  is  a  mistake  to  assume 
that  increased  cancer  mortality,  is  a  necessary  corollary  of  the 
survival  of  augmented  numbers  to  the  cancer  age.  The  average 
age  of  the  Irish  population  is  very  much  higher  than  that  of 
either  England  or  Scotland,  owing  to  the  large  number  of 
elderly  people  left  behind  after  the  younger  ones  have  emi- 
grated ;  yet  the  cancer  mortality  of  Ireland  is  much  less  than 
that  of  either  England  or  Scotland.  Hence  it  is  doubtful 
whether  the  higher  age  of  the  agricultural,  as  compared  with 


Longstaft',  "Studies  in  Statistics,"  p.  256 


HEALTH    OF    CANCER    PATIENTS.  285 

the  industrial  population,  in  any  way  explains  the  greater 
proneness  of  the  former  to  cancer. 

In  conclusion  I  must  direct  attention  to  the  remarkable 
decline  in  the  death  rate  from  phthisis  and  other  tubercular 
diseases  that  has  coincided  with  the  great  increase  in  the 
cancer  mortality.  The  following  data  from  the  fifty- second 
report  of  the  Registrar-General  indicate  its  extent. 

Table    Showing    the    Annual    Mortality    per    Million    Living 

FROM  Cancer,  Phthisis,  and  other  Tubercular  Diseases 

IN  Groups  of  Years  from   1861-1889. 

1861-65.  1866-70.  1871-75.  1881-85.  1886-89. 

Cancer          376  403  415  544             610 

Phthisis        2526  2447  2218  1820           1598 

Other  tubercular  diseases         784  752  722  706             674 

I  regard  this  decline  in  the  prevalence  of  tubercular  disease,  as 
the  outcome  of  improved  hygienic  conditions,  due  to  that 
augmented  prosperity,  which  I  have  endeavoured  to  show,  by 
its  action  in  another  direction,  is  also  responsible  for  the 
increased   cancer  mortality. 

It  seems  to  me  exceedingly  probable,  from  considerations 
derived  from  the  study  of  the  family  history  of  cancer  patients, 
that  a  large  proportion  of  those  thus  saved  from  tubercle 
eventually  perish  of  cancer  and  insanity  ;  and  I  think  the 
increase  in  the  latter  diseases  has  largely  been  brought  about 
in  this  way. 

§   VI. The  General  Health  of  Cancer  Patients. 

Long  continued  observation  of  cancer  patients  in  the  early 
stage  of  the  disease  has  convinced  me,  that  most  of  those 
affected  are  large,  robust,  well-nourished,  florid  persons,  who 
appear  to  be  overflowing  with  health  and  vitality  ;  and  they 
often  present  a  considerable  amount  of  embonpoint.  Mr.  and 
Mrs.  John  Bull,  as  so  frequently  depicted  in  the  pages  of 
Punch,  are  the  physical  types  of  the  majority  of  cancer  patients. 
Such  types  are  indicative  of  general  hyper-nutrition. 


286         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

At  first  there  seems  to  be  some  difficulty  in  reconciling  this 
appearance  of  rude  health  with  the  conclusion  previously 
arrived  at,  that  most  cancer  patients  are  the  surviving  members 
of  tubercular  families  ;  but  in  reality  there  is  here  no  contradic- 
tion, for  it  commonly  happens  that  the  surviving  members  of 
tubercular  families,  although  they  never  develop  cancer,  are 
remarkable  for  their  robust  and  vigorous  constitutions.  The 
famous  Astley  Cooper  was  a  striking  example  of  this ;  yet  he 
was  of  a  very  tubercular  family,  having  lost  five  near  relatives 
of  this  disease ;  moreover,  in  his  youth  he  had  haemoptysis, 
which  was  rightly  supposed  to  be  due  to  pulmonary  tubercle, 
for  when  in  accordance  with  his  last  instructions  his  body  was 
submitted  to  post-niortein  examination,  a  healed  tubercular 
lesion  was  found  at  the  apex  of  his  lung.  According  to  my 
views  he  was  a  very  likely  subject  for  cancer,  and  although  he 
escaped,  it  would  be  interesting  to  know  whether  his  descen- 
dants have  been  equally  fortunate. 

Beneke^"  describes  cancer  patients  as  having  large  hearts 
and  wide  arteries,  with  small  lungs,  large  livers,  and  long,  large 
capacious  intestines.  This  quite  accords  with  what  I  have 
myself  observed,  that  cancer  patients  usually  are  of  a  coarse 
physical  type.  Those  recently  attacked  never  present  a 
cachectic  appearance.  The  small,  pale,  ill-nourished,  and  over- 
worked women  of  the  type  so  familiar  in  Lancashire  and  other 
large  industrial  centres,  are  seldom  the  victims  of  this  disease 

It  is  remarkable  how  little  the  general  nutrition  of  breast 
cancer  patients  often  appears  to  suffer — in  the  absence  of 
ulceration — even  when  the  disease  has  lasted  for  a  considerable 
time. 

Of  75  consecutive  cases  of  this  kind,  when  they  first  came  under  my 
observation,  4  were  markedly  cachectic  or  sallow  (primary  3,  recurrent  i), 
8  were  emaciated  (primary  6,  recurrent  2),  and  14  pale  (primary  10,  re- 
current 4)  ;  the  remaining  57  (primary  47,  recurrent  10)  were  well  nourished 
and  healthy-looking,  7  of  them  being  obese. 

*"  "  Constitution  und  constitutionelles  Kranksein  des  Menschen."  Marburg,  1887. 


HEALTH    OF    CANCER    PATIENTS.  287 

It  accords  with  the  foregoing  that  the  natural  functions  of 
cancer  patients  are  almost  invariably  performed  with  ease  and 
regularity.  In  women  with  cancer  of  the  breast,  as  I  have 
previously  mentioned,^''  the  catameiiial  function  is  seldom  dis- 
turbed. That  it  is  established  earlier  and  ceases  later  than  in 
the  generality  of  women  is  also  a  sign  of  vigorous  health. 
Just  so  is  it  with  regard  to  marriage;  for  a  greater  pro- 
portion of  the  subjects  of  mammary  cancer  marry  than  of  the 
female  population  of  corresponding  age.  According  to  Gross,^^ 
of  1,545  women  with  mammary  cancer,  85*5  per  cent,  had 
married,  and  I4'5  per  cent,  were  single,^^  whereas  in  the  general 
population  only  79  per  cent,  of  women  over  24  ever  marry.''*' 
Such  facts  have  induced  some  pathologists  to  regard  marriage 
as  per  se  a  cause  of  cancer,  but,  as  it  seems  to  me,  without 
sufficient  reason. 

The  amount  of  sterility  among  married  cancerous  women  is 
almost  identical  with  that  existing  in  the  general  community. 
Of  98  married  women  with  breast  cancer,  under  my  observation, 
12  were  absolutely  sterile  (never  pregnant),  but  two  of  these 
had  not  married  until  over  40.  Of  1,034  similar  cases  analysed 
by  Gross,  127,  or  12*2  per  cent.,  were  barren.  Among  married 
women  in  the  general  community,  the  amount  of  sterility  has 
been  estimated  by  Simpson  at  1  r6  per  cent.  Modern  statistics 
afford  no  support  to  Astley  Cooper's ^^  dictum,  "that  married 
women  who  bear  no  children,  and  single  women,  are  more 
subject  to  this  complaint  than  those  who  have  had  large 
families." 

Fourteen  of  the  above  mentioned  98  women  produced  only 
a  single  child,  that  is,  about  i  in  6  of  the  fertile :  the  ratio  of 
one-child    sterility  for   fertile   married    women    of  the   general 


"  p.  245- 

"'  International  lour.  Med.  Sciences,  March,  1888,  p.  220. 

°*  Of  154  consecutive  cases  of  mammary  cancer  under  my  observation,  80  were 
married,  30  widowed,  and  44  were  single . 
'»  Farr,  "  Vital  Statistics,"  p.  20. 
"   "  Lectures  on  Surgery,"  1S39,  p.  378. 


265         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

population,  according  to  Ansell,  is  i  in  13 — but  5  of  the  patients 
in  my  list  had  not  married  until  between  the  ages  of  32  and  42. 
Gross  has  estimated  the  amount  of  one-child  sterility  among 
fertile  breast  cancer  patients  at  i  in  10. 

The  remaining  68  of  these  married  cancer  patients  all  had 
more  than  a  single  child,  the  maximum  offspring  being  16 
children  ;  the  average  4*8  children  each. 

Of  74  of  these  fruitful  cancerous  women,  34  had  miscarried 
— the  maximum  number  of  times  being  13,  the  minimum  i  — 
of  which  there  were  20  instances ;  the  average  number  i"4  each. 

To  sum  up,  98  married  cancer  patients  had  between  them 
340  children  and  112  miscarriages;  which  gives  an  average  of 
3"4  children  and  I'l  miscarriages  each.  This  amount  of  fertility 
probably  about  equals  the  average  in  the  general  community 
(4*6  children  per  marriage) ;  when  allowance  has  been  made  for 
the  fact,  that  a  certain  proportion  of  cancerous  women  die  before 
the  completion  of  their  reproductive  life. 

The  average  age  of  these  patients  at  their  first  marriage 
was  24*9  years,  and  the  average  age  at  which  they  com- 
menced child-bearing  26"2  years.  These  figures  differ  but 
little  from  the  corresponding  averages  for  married  women  of 
the  general  community.  It  is  evident  from  the  above  facts, 
that  the  fertility  of  cancer  patients  of  itself  has  nothing  what- 
ever to  do  with  the  causation  of  their  disease. 

With  regard  to  lactation,  Gross'  statistics  show  that  of  416 
breast  cancer  patients,  316,  or  ^6  per  cent,  had  suckled  ;  while 
100,  or  24  per  cent,  had  not.  Of  1 10  cases  tabulated  by  Velpeau, 
60  had  suckled,  or  5454  per  cent. ;  and  50,  or  45*46  per  cent., 
had  not.  Winiwarter  analysed  102  cases,  with  the  result  that 
65  had  suckled,  or  63-8  per  cent. ;  and  37  had  not,  or  36-2  per 
cent.  These  data  afford  no  proof  that  suckling  predisposes 
to  cancer  ;  and  I  am  at  a  loss  to  find  any  justification  for  the 
assertion  that  the  breasts  of  married  women,  and  of  those  in 
whom  the  gland  has  been  active,  are  more  liable  to  cancer  on 
this  account,  than  are  the  breasts  of  single  and  sterile  women. 
Mammary  cancer  is  a  disease  not  of  the  active  breast,  but  of 


HEALTH    OF    CANCER    PATIENTS.  289 

the  breast  becoming  obsolete.  Of  71  prolific  women  with 
mammary  cancer,  I  have  found  that  in  no  less  than  55  (77*4  per 
cent.),  the  disease  did  not  commence  until  after  child-bearing 
had  ceased.  Rarely  does  it  arise  during  pregnancy  or  lactation. 
Of  71  prolific  women  the  subjects  of  breast  cancer,  interrogated 
by  me,  in  3  the  onset  of  the  disease  coincided  with  childbirth, 
and  in  2  with  miscarriage,  and  in  4  it  occurred  during  the 
lactation  period.  In  none  of  these  cases  was  the  subsequent 
progress  of  the  disease  in  any  way  different  from  the  ordinary. 
In  several  cases  women  with  cancer  already  developed  subse- 
quently became  pregnant,  and  in  due  time  gave  birth  to  chil- 
dren, without  any  interference  with  the  ordinary  course  of  the 
disease.  It  is  evident,  therefore,  that  the  acute  cancers  some- 
times met  with  during  pregnancy  and  lactation  are  highly 
exceptional. 

From  the  foregoing  it  will  be  gathered  that  the  due  discharge 
of  natural  functions  in  no  way  predisposes  to  cancer. 

In  the  present  imperfect  state  of  our  knowledge  it  is  very 
difficult  adequately  to  estimate  the  influence  of  alimentation  in 
the  causation  of  cancer.  This  difficulty  is  singularly  increased 
by  the  consideration,  that  the  effects  of  diet  in  this  direction 
probably  only  become  appreciable  after  more  than  a  single 
generation  of  individuals  has  been  exposed  to  them.  Hence 
the  failure  of  the  praiseworthy  attempt  of  the  British  Medical 
Association's  -Collective  Investigation  Committee  to  solve  this 
problem.^^  From  returns  collected  by  this  committee  it  appears 
that  of  194  cancer  patients,  123  had  been  moderate  eaters,  59 
small  eaters,  and  12  large  eaters.  With  regard  to  meat,  99  had 
been  moderate,  78  small,  and  16  large  eaters.  There  was  not 
a  single  strict  vegetarian  among  them  ;  and  only  a  few  had 
been  great  eaters  of  vegetables. 

That  cancer  is  much  less  prevalent  in  vegetarian  than  in 
flesh-eating  communities  is  generally  believed  ;  and  the  following 
considerations  are  favourable  to  this  view.      In   Ireland,  where 

"  British  Medical  Journal,  February  26,  1SS7. 

^9 


290        GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

a  large  proportion  of  the  population  live  chiefly  on  vegetable 
diet,  the  prevalence  of  cancer,  as  I  have  previously  pointed 
out,  is  much  less  than  in  either  of  the  sister  countries  ;  and 
Beneke's  statistics,"  show  that  cancer  is  very  rare  in  prisons, 
where  but  little  animal  food  is  allowed,  and  hard  work  is 
exacted.  The  remakable  fact  that  in  New  Zealand  men  are 
more  liable  to  cancer  than  women  is  probably  due,  as  Mac- 
Donald  reports,''^  to  their  gluttonous  habits  in  respect  to  meat 
eating.  "  Meat  for  breakfast,  lunch,  dinner,  tea  and  supper,  just 
like  the  porridge  pot  in  Scotland."  The  greater  prevalence  of 
cancer  in  rural  than  in  urban  districts,"  and,  in  the  latter,  its 
greater  prevalence  in  those  localities  where  the  well-to-do  and 
easy-going  reside,  rather  than  among  the  poor  and  working 
classes,  point  to  the  same  conclusion."^  It  is  certain,  however, 
that  vegetarians  are  not  exempt  from  cancer;  for  of  102  cancer 
patients  operated  on  at  the  Jeypore  Hospital  during  the  period 
of  1880-88,  61  were  strict  vegetarians  and  41  meat  eaters." 
Meat-eating  communities  are,  as  a  rule,  also  rt/(r^//(?/ consuming. 
There  is,  however,  no  evidence  that  the  habitual  consumption 
of  alcoholic  liquors  per  se  in  any  way  predisposes  to  cancer. 
The  British  Medical  Association's  inquiry  indicates  that  the 
effect  of  this  habit  has  rather  the   opposite  tendency.''*     The 


'3  Op.  cit. 

'*  "Cancer  Statistics  of  New  Zealand,"  New  Zealand  Medical  /ourttal,  February, 
1890. 

■^  This  was  long  ago  demonstrated  by  Walshe  ("Nature  and  Treatment  of 
Cancer,"  1846,  p.  16,  et  seq.)  Subsequent  investigations  have  fully  confirmed 
Walshe's  conclusion,  especially  those  of  the  late  Registrar-General,  q.  v.,  47th 
Annual  Report,  Table  J,  p.  xxi. 

'*  §  in.  The  facts  there  cited  prove  conclusively  the  greater  frequency  of  cancer 
among  the  well-to-do  than  among  the  poor  and  working  people.  Hofmeier  {Zeitschr. 
f.  Gelnirts.,  &c.,  Bd.  x.,  S.  270),  states  that  of  16,800  patients  at  the  Berlin  Polyclinic, 
603,  or  3*6  per  cent.,  suffered  from  uterine  cancer  ;  whereas  in  Schroeder's  private 
practice,  of  9,400  patients,  299,  or  2'i8  percent.,  were  similarly  affected.  I  have 
often  seen  these  data  quoted  as  evidence  of  the  greater  prevalence  of  cancer  among 
the  poor  than  the  rich ;  but  this  is  a  conclusion  that  cannot  fairly  be  drawn  from 

them. 

'■  Hendley,  British  Medical  Journal,  July  7,  1888. 

"  British  Medical  Journal,  January  23,  1888.     Dr.  Owen's  Report. 


HEALTH    OF    CANCER    PATIENTS.  29  T 

exemption  of  savages  from  cancer,  and  its  great  prevalence  in 
civilised  communities  is  probably  largely  attributable  to  the 
influence  of  diet.  At  any  rate,  it  is  certain  that  savages 
are,  as  a  rule,  less  well  fed  than  are  the  members  of  modern 
communities. 

According  to  Rommelacre,''''  the  amount  of  urea  and  phos- 
phates in  the  urine  of  cancer  patients  is  markedly  below  the 
normal,  independently  of  alimentation  ;  and  Schopp^"  has  lately 
published  an  account  of  some  experiments  as  to  the  alleged 
diminished  elimination  of  chlorides  in  their  urine. 

The  ensemble  of  the  facts  relating  to  the  life  history  of 
mammary  cancer  patients  shows,  that  they  have  almost  in- 
variably led  regular,  sober,  and  industrious  lives.  Persons  of 
drunken  and  dissolute  habits  are  comparatively  seldom  affected. 
Of  165  female  breast  cancer  patients  consecutively  under  my 
observation,  not  a  single  one  had  ever  been  addicted  to  prosti- 
tution, so  far  as  I  could  ascertain  ;  and,  what  is  still  more 
remarkable,  there  was  not  among  them  a  single  individual  who 
presented  undoubted  signs  of  having  had  syphilis.  In  this 
connection  the  almost  complete  immunity  of  mammary  cancer 
patients  from  chronic  ulcer  of  the  leg  is  well  worth  noting.  Of 
165  patients  consecutively  under  my  observation,  there  was 
not  a  single  instance  of  it.  There  is,  however,  no  absolute  in- 
compatibility between  the  two  diseases,  for  on  analysing  597 
consecutive  cases  of  breast  cancer,  T  have  found  that  two 
patients  had  as  well,  chronic  ulcer  of  the  leg.  The  great 
rarity  of  the  coincidence  of  these  two  diseases — each  of  itself 
so  common  in  women  over  middle  age— is  certainly  very  re- 
markable. I  have  seen  it  stated  that  the  subjects  of  osteitis 
deformans  are  specially  prone  to  malignant  disease.  With 
regard  to  this  I  can  only  say  that  of  over  1,000  cases  of 
malignant  disease  investigated  by  me,  and  of  which  I  now 
have    written    records,  not   a   single   one   was    complicated  by 


'^  yournalde  Med.  de  Bt-uxelks,  1883-84. 

""  Deutsche  med.   Wock.,  No.  46,  S.  1155,  1893. 


292         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER, 

this  disease;  170  cases  of  breast  cancer  in  women  are  included 

in  this  list. . 

The  occupation  usually  followed  by  these  patients  was  noted 

in  144  cases,  as  follows  : — 

Of  80,  married — housewife,  66  ;  governess,  2  ;  laundress,  2  ;  nurse,  2  ; 
and  one  each  as  follows  :  straw  hat  factory,  needlework,  boot  factory,  cook, 
mantle-maker,  tailor,  servant,  charwoman.  Of  20,  widowed — housework,  8  ; 
laundry,  3  ;  cook,  2  ;  monthly  nurse,  2  ;  and  one  each  as  follows  :  dress- 
maker, paper-factory,  factory,  midwife,  lady's  maid.  Of  44,  single— cook,  9 ; 
servant,  9  ;  dressmaker,  5  ;  at  home,  4  ;  governess,  2  ;  school  teacher,  2  ; 
and  one  each  as  follows  :  staymaker,  nursery,  lady's  companion,  monthly 
nurse,  upholstress. 

Sonne  authors,  following  the  example  of  Astley  Cooper,^^ 
have  attached  great  importance  to  grief,  anxiety,  and  mental 
distress  as  causes  of  cancer  ;  and  they  have  adduced  statistics 
in  support  of  their  belief  I  am  unable  to  confirm  this.  The 
majority  of  cancer  patients  whose  life  history  1  have  investi- 
gated, appeared  to  me  to  have  been  less  exposed  to  depressing 
influences  of  this  kind  than  most  women  of  corresponding  age 
in  the  general  population. 

I  have  often  noticed  on  the  face,  chest,  and  upper  limbs  of 
breast  cancer  patients  minute,  pink  telangiectases ;  but  these 
are  also  commonly  seen  on  the  non-cancerous  of  corresponding 
age.  The  small  outgrowths  of  warty  or  dermoid  structures, 
said  by  De  Morgan  to  coincide  with  or  follow  the  development 
of  cancer,  I  have  very  rarely  seen  in  association  with  breast 
cancer ;  nor  have  I  noticed  that  eczema,  psoriasis,  or  other 
dermatoses  often  appear  in  the  course  of  this  disease,  as  Bazin 
and  Hardy  allege. 

In  conclusion,  I  must  here  express  entire  concurrence  with 
Moore's  statement  :  "  that  cancer  is  eminently  a  disease  of 
persons  whose  previous  life  has  been  healthy,  and  whose  nutritive 
vigour  gives  them  otherwise  a  prospect  of  long  life." 

Some  idea  of  the  non-cancerous  morbid  conditions  to  which 
women  with  cancer  of  the  breast  are  liable  may  be  gathered 
from  the  subjoined  analytical  statements. 

"'  He  says  ("Lectures  on  Surgery,"  1839,  p.  383),  "Fully  three-fourths  of  these 
cases  arise  from  grief  and  anxiety  of  mind." 


HEALTH    OF    CANCER    PATIENTS.  293 

(i)  In  165  consecutive  patients  the  following  associated 
lesions,  &c.,  were  noticed  when  they  first  came  under  observa- 
tion : — 

Arcus  senilis  in  5,  pains  in  the  limbs  (chiefly  thighs)  in  4,  scanty  beard 
and  moustache  in  3,  old  corneal  leucomata  in  2,  lipoma  in  2,  molluscum 
fibrosum  (large  and  pendulous)  in  2,  scars  of  old  abscesses  of  neck,  &c., 
in  2,  varicoid  capillaries  of  cheeks  in  2,  extreme  deafness  in  2,  spontaneous 
fracture  of  femur  in  2,  and  each  in  one  case — whitlow,  lobular  hypertrophy 
of  opposite  breast  and  scars  of  old  abscesses,  general  tubercular  enlarge- 
ment of  lymphatic  glands  and  scars  of  old  abscesses,  old  anchylosis  of  knees 
after  suppurative  white  swelling,  jaundice,  nausea  and  vomiting,  bronchitis, 
pneumonia,  erythema,  pasty  swollen  face  from  renal  disease,  chronic 
alcoholism,  bronzed  complexion,  freckled  complexion,  smallpox  pitted, 
internal  strabismus  (R.),  enlarged  thyroid,  enlarged  lymph  gland  of  sub- 
maxillary region,  cataract  and  posterior  synechiae. 

(2)  Of  130  breast  cancer  patients,  whose  previous  health  was 
investigated,  100  stated  that  it  had  been  habitually  good  (with 
no  serious  illness  since  youth  in  52),  19  that  it  had  been  in- 
different, and  1 1  that  it  had  been  bad. 

The  following  previous  diseases  were  noted  as  having  oc- 
curred among  these  patients  since  childhood  : — 

Bronchitis  in  17  cases,  rheumatic  fever  in  1 1,  typhoid  fever  in  1 1,  chronic 
rheumatism  in  6,  phthisis  in  5,  ulceration  of  uterus  in  4,  small-pox  in  4, 
erysipelas  in  4,  dyspepsia  in  3,  alcoholism  in  3,  scarlet  fever  in  3,  haemor- 
rhoids in  2,  migraine  in  2,  varicose  veins  of  legs  in  2,  peritonitis  in  2,  and 
each  in  one  case — extreme  myopia,  glaucoma,  iritis,  neuralgia,  disorganised 
eyeball,  corneal  ulcers,  femoral  hernia,  enlarged  cervical  glands,  quinsy, 
fistula-in-ano,  suppurative  white  swelling  of  knee,  measles,  otorrhoea, 
ulcerated  sore  throat,  heart  disease,  laryngitis,  cholera,  phlegmasia  dolens, 
small  fibro-adenoma  of  breast  (35  years'  duration),  jaundice  and  gallstones, 
diphtheria,  cystitis,  nervous  debility,  intermittent  fever,  syncopal  attacks, 
hypertrophied  tonsils. 

(3)  Post-mortem  examination  of  the  bodies  of  44  women, 
the  subjects  of  breast  cancer,  revealed  the  presence  of  the 
following  non-cancerous  lesions,  &c. : — 

The  general  condition  of  the  body  was  noted  in  40  cases — 

It  was  emaciated  in  18  ;  well-nourished,  11  (obese,  5) — of  these  8  (obese 
2)  had  died  shortly  after  operation — moderately  nourished,  7  (of  these  2  had 
died  shortly  after  operation)  ;  sallow,  2  ;  icteric,  2  ;  bronzed  and  mottled,  i. 

Lungs.— 0\d.  pleural  adhesions  in  24  cases  (general  in  16 — both  lungs  in 
13,  one  lung  in  3 — in  8  cases  adhesions  confined  to  one  or  both  upper  lobes)  ; 
emphysema  in   12  ;  acute  pleurisy  with  eftusion  in  11  (6  of  these  of  septic 


294         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

origin,  4  due  to  invasion  of  thorax  by  direct  extension  of  the  primary 
disease,  and  i  secondary  to  tubercular  pneumonia) ;  collapse  of  lung  in  7 
(in  5  cases  secondary  to  acute  pleural  effusion  and  in  2  to  invasion  of  thorax 
by  cancer) ;  congestion  in  6  ;  phthisis  in  6  (the  phthisical  lesions  in  4  cases 
were  in  the  form  of  old  scarring  and  pigmentation  at  each  apex  associated 
with  old  pleural  adhesions,  and  in  i  of  these  cases  with  a  cavity  and  in 
another  with  caseous  old  nodules  as  well  ;  in  the  other  2  cases  the  disease 
was  in  active  progress  ;  in  i  there  was  a  large  cavity  surrounded  by  tuber- 
cular consolidation,  and  in  the  other  almost  the  whole  of  both  lungs  were 
consolidated  by  caseous  tubercle,  with  cavities  and  softening  in  places)  ; 
bronchitis  in  5  ;  hydro-thorax  in  3  ;  each  in  i  case — recent  pleural  adhe- 
sions, old  dried-up  empyema  with  partial  collapse,  hypostatic  pneumonia. 
In  not  a  single  instance  were  both  lungs  normal. 

Heart. — Small  and  atrophied  in  5  cases  ;  atheroma  of  aortic  arch  in  5  ; 
atheroma  and  thickening  of  mitral  valve  in  4  ;  atheroma  and  thickening  of 
tricuspid  valve,  &c.,  in  3  ;  atheroma  of  aortic  valves  in  2  ;  large  aneurism  of 
aortic  arch  in  2  ;  walls  of  heart  soft  and  flabby  in  2  ;  milk-white  patch  on 
anterior  surface  of  ventricles  in  2  ;  acute  pericarditis  (septic,  i  ;  secondary 
to  invasion  by  cancer,  i)  in  2  ;  and  each  in  i  case— mitral  stenosis,  atheroma 
of  pulmonary  valves  and  aorta,  general  hypertrophy,  excess  of  fat  on  surface, 
deeply  stained  endocardium.     In  25  cases  the  heart  was  normal. 

Liver. — Fatty  in  17  cases  ;  gall-stones  in  7  (or  in  16  per  cent,  of  these 
44  cancer  necropsies)  ;  *-  nutmeg,  3  ;  cirrhosis,  3  ;  congestion,  3  ;  small,  2  ; 
cloudy  swelling,  i  :  and  multiple  angioma  in  i  case.  In  only  a  single  case 
was  the  liver  normal. 


^-  This  percentage  of  gall-stones  is  twice  as  high  as  that  which  is  stated  to  hold 
for  women  who  have  died  of  causes  other  than  cancer.  According  to  Schroeder,  gall- 
stones are  met  with  in  from  5  to  12  per  cent,  of  all  necropsies — females  20'6  and 
males  4*4  per  cent.  This  is  a  German  estimate.  In  England  gall-stones  are  prob- 
ably not  so  common.  Of  777  necropsies,  mostly  on  adults,  at  the  Manchester  In- 
firmary, gall-stones  were  found  in  34,  or  only  in  4*4  per  cent ;  of  228  necropsies  on 
females,  they  were  met  with  in  18,  or  7*9  per  cent.  ;  and  of  542  necropsies  on  males 
in  16,  or  in  2*9  per  cent.  (Brockbank,  Med.  Chronicle,  Dec,  1893).  Of  281  necrop- 
sies for  surgical  cancer  analysed  by  me,  gall-stones  were  found  in  18,  or  in  6*4  per 
cent.  ;  181  were  females  with  gall-stones  in  14,  or  in  77  per  cent.  ;  100  were  males, 
with  gall-stones  in  4.  Of  the  foregoing,  79  necropsies  were  for  uterine  cancer,  with 
gall  stones  in  5,  or  in  6"3  per  cent.  ;  and  52  for  cancer  of  the  tongue  and  mouth  in 
males,  with  gall-stones  only  in  a  single  case.  It  has  been  stated  that  gall-stones  are 
more  frequently  found  associated  with  cancer  of  the  stomach  and  liver  than  with  any 
other  forms  of  cancer.  I  have  not  tested  this  statement,  and  no  cancers  of  these 
localities  are  included  in  my  analysis,  which  shows  that  gall-stones  are  more  fre- 
quently found  in  association  with  breast  cancer  than  with  any  other  surgical  form  of 
the  disease.  Gall  stones  are  frequently  found  in  the  bodies  of  those  who  die  insane. 
Snell's  analysis  gives  the  percentage  as  I9"4  for  females  and  9*2  (or  males  {Neurol. 
Cenlralbl.,  June  i,  1893).  In  the  female  insane  Beadles  met  with  gall-stones  in  36 
per  cent.  Gall-stones  are  also  of  very  frequent  occurrence  in  the  tubercular  {Jourtial 
Mental  iici.,  July,  1892). 


TRAUMATA,  INFLAMMATION  AND  CANCER.      295 

Spleen. — Large  and  congested  in  5,  very  small  in  2,  and  normal  in  35 
cases. 

Kidneys. — Chronic  interstitial  nephritis  (small  and  granular  kidneys)  in 
16  cases  ;  fatty  in  5  ;  renal  calculi  (uric  acid,  2  ;  phosphatic,  i)  in  3  ;  con- 
gestion, 2  ;  acute  pyelitis  (associated  with  acute  cystitis)  in  i  case  :  cloudy 
swelling  in  i  ;  very  small  in  i  case.     In  18  cases  the  kidneys  were  normal. 

Gastro-Intestinal  Tract. — Acute  peritonitis  in  2  cases  (i  due  to  perfora- 
tion, I  to  secondary  cancer)  ;  gastric  catarrh  in  i  case  ;  femoral  omental 
hernia  in  i  ;  ascites  in  i  ;  fistula  between  gall-bladder  and  duodenum 
(owing  to  blocking  of  common  bile  duct  by  cancerous  growth  in  head  of 
pancreas)  in  i  case.     In  38  cases  the  gastio-intestinal  tract  was  normal. 

Other  Lesions. — Uterine  fibro-myomata  in  5  cases  ;  soft  polypi  of  uterus 
in  3  cases  ;  and  each  in  i  case — dermoid  cyst  of  ovary,  small  parovarian 
cysts,  small  multilocular  ovarian  cystomata,  pyometria  and  pyo-salpinx 
(owing  to  occlusion  of  the  os  uteri),  old  un-united  fracture  of  neck  of  femur, 
spontaneous  fracture  of  both  femora  (part  of  general  fragilicas  ossium  un- 
associated  with  secondary  growth),  cold  abscess  in  axilla  (on  side  opposite 
to  the  cancerous  breast). 


^   VII. Traumata,  Chronic  Inflammation  and  Cancer. 

Those  who  maintain  that  cancers  are  caused  by  traumata, 
must  explain  how  it  is  that  men,  who  suffer  nearly  three  times 
as  often  from  traumata  as  women,  are  nevertheless  only  about 
half  as  liable  to  cancers. 

Thus,  of  9,229  consecutive  cases  of  traumata  under  treatment 
at  four  large  Metropolitan  hospitals,  I  have  found  that  6,856  were 
males,  and  2,373  females,  or  2*89  males  to  i  female.  Similarly, 
of  240,063  deaths  from  traumata,  tabulated  by  the  Registrar- 
General  for  the  twenty-five  years,  1872-48,  178,005  were  males 
and  62,058  females,  or  2*8  males  to  i  female. 

On  the  other  hand,  of  7,878  consecutive  cases  of  cancer  under 
treatment  at  the  above-mentioned  hospitals,  2,861  were  males 
and  5,017  females,  or  1  male  to  17  females.  Similarly,  of  the 
19,433  cancer  deaths  in  England  and  Wales  during  1890,  7,137 
were  males  and  12,296  females,  or  i  male  to  17  females. 

Evidently  either  these  facts  must  be  refuted,  or  the  theory  of 
the  traumatic  causation  of  cancer  must  be  given  up. 

Still  more  cogent  is  reasoning  of  this  kind  when  applied  to 
cancer  of  the  breast ;  for  whereas  men  are  quite  three  times  as 


296         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

liable  to  traumata  of  this  part  as  women,  yet  they  suffer  from 
mammary  cancer  only  in  the  proportion  of  16  to  1,863,  or  of  i 
male  to  116  females.  Moreover,  were  mammary  cancers  thus 
caused,  the  nipple,  areola  and  skin  would  be  more  frequently 
affected  than  other  parts  of  the  breast ;  but  the  actual  propor- 
tion of  cancers  that  arise  from  the  nipple  only  amounts  to 
i"3i  per  cent.,  while  the  areola  and  skin  of  this  region  enjoy 
still  more  remarkable  immunity.  This  completely  negatives 
the  alleged  causation  of  mammary  cancer  by  pressure  of  the 
corset,  injury  of  the  nipples  in  suckling,  &c.,  &c. 

Again,  the  initial  lesion  of  cancer  is  almost  invariably 
solitary ;  whereas  if  the  disease  were  of  traumatic  origin  it 
would  often  be  multiple.  It  is  a  curious  circumstance  that  the 
advocates  of  the  traumatic  theory  of  cancer  should  have  over- 
looked these  obvious  facts. 

They  base  their  belief  in  it  on  statements  made  by  the 
patients  themselves  as  to  the  antecedent  occurrence  of  traumata. 
Of  137  women  with  mammary  cancer  interrogated  by  me,  35 
gave  a  history  of  antecedent  traumata,  or  25*5  per  cent.  ;  in 
other  words,  the  most  careful  investigation  directed  expressly 
to  this  point,  failed  to  elicit  any  previous  history  of  trauma 
in  74-5  per  cent,  of  all  cases.  Many  of  the  above  affirmations 
appeared  to  me  to  be  the  outcome  of  imagination,  rather  than 
of  any  real  causal  relationship ;  and  in  no  case  was  there  evidence 
that  the  disease  had  developed  out  of  induration  or  other  obvious 
lesion  thus  induced.  Injury  was  often  merely  the  means  of 
directing  the  patient's  attention  to  the  previously  existing 
disease,  of  which  she  had  been  until  then  unconscious.  Of 
1,000  cases  of  cancer  consecutively  under  my  observation,  there 
was  but  a  single  instance  in  which  the  disease  immediately  fol- 
lowed an  injury,  and  this  was  a  case  of  so-called  acute  traumatic 
malignancy.  Yet  if  traumata  were  the  efficient  causes  of  cancer, 
such  occurrences  would  be  quite  common,  instead  of  being  so 
infinitely  rare.  Moreover,  we  cannot  produce  cancer  by  any 
kind  of  traumatism,  even  in  those  who  are  already  subject  to 
the  disease,  and  their  wounds  heal  just  as  do  those  of  the  non- 


TRAUMATA,    INFLAMMATION    AND    CANCER.  297 

canceroub.  Again,  if  the  traumatic  theory  of  cancer  were  true, 
those  parts  of  the  body  most  subject  to  injuries,  such  as  the 
upper  and  lower  extremities,  the  head,  face  and  neck,  would  be 
the  commonest  seats  of  the  disease,  but  its  actual  localisation 
is  totally  different. 

Though  a  blow,  wound,  or  other  injury  may  sometimes  pre- 
cipitate the  formation  of  a  cancer,  yet  it  appears  to  me,  from  the 
foregoing  considerations,  that  such  stimuli  are  of  themselves  in- 
adequate to  originate  the  disease  ;  the  final  outbreak  in  these 
cases  is  but  the  explosion  of  a  long  train  of  antecedent  prepara- 
tion. I  regard  the  relation  of  trauma  to  cancer — to  borrow  a 
Darwinian  simile — as  resembling  that  of  a  spark  in  contact  with 
combustible  matter,  the  result  depending  upon  the  nature  of  the 
latter,  rather  than  upon  the  spark  itself. 

It  is  often  asserted  that  cancers  of  the  breast  are  due  to 
antecedent  attacks  of  inflammation  or  abscess  of  the  affected 
part,  yet  no  conclusive  evidence  of  this  has  ever  been  adduced. 
Equally  destitute  of  support  is  the  constantly  reiterated  assertion, 
that  the  latter  lesions  are  of  more  frequent  occurrence  in  the 
cancerous  than  in  the  non-cancerous.  The  following  facts  are 
conclusive  in  this  respect. 

WinckeP  has  estimated  that  after  1000  consecutive  accouchenients 
mastitis  developed  in  6  per  cent.  This  of  course  refers  only  to  its  frequency 
after  single  deliveries  in  a  succession  of  women  ;  and  not  to  the  frequency 
of  its  occurrence  in  regard  to  the  total  pregnancies  of  each  woman  during 
her  entire  puerperal  life.  To  obtain  the  latter  datum  Winckel's  percentage 
must  be  multiplied  by  4"6,  this  being  the  average  number  of  accouchenients 
of  each  married  woman.  Reckoned  in  this  way  it  will  be  found,  that 
27'6per  cent  of  all  fertile  married  women  have  suffered,  at  some  period  or 
other  of  their  puerperal  life,  from  inflammatory  disease  of  the  breast.  In 
order  to  ascertain  what  proportion  of  mammary  cancer  patients  suffer  from 
similar  affections  I  made  special  inquiries  on  this  subject  in  137  cases.  Of 
these  only  24,  or  I7"5  per  cent.,  gave  a  history  of  some  previous  disease  of 
the  breast — abscess  in  15,  sore  nipple  in  8,  and  inflammation  in  i  ;  and  in 
6  of  these  cases  the  nipples  were  congenitally  malformed.'" 


'^  Path.  u.  Therap.  des  Workenb.     1878. 

**  In   thirteen  other  cases,   imassociated  with  any  previous  inflammatory  lesion, 
the  nipples  were  also  congenitally  malformed. 


298         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

The  above  facts  prove  that  the  only  basis  for  this  alleged 
causation  is,  that  in  a  certain  proportion  of  cancer  cases, 
inflammatory  lesions  have  pre-existed.  Moreover,  against  the 
assumed  etiological  importance  of  previous  inflammatory 
disease  is  the  fact,  that  in  most  of  the  cases  the  interval  between 
the  antecedent  disease  and  the  subsequent  outbreak  of  cancer 
extended  over  many  years,  and  during  this  period  the  breast 
appeared  to  be  free  from  any  lesion.  Of  like  import  is  the 
consideration  that  cancer  of  the  breast  is  relatively  almost  as 
frequent  in  the  single  and  sterile  as  in  the  married,  although 
the  former  are  much  less  prone  to  inflammatory  affections  of 
the  breast  than  the  latter.  On  a  priori  grounds,  no  inflam- 
matory lesion  seems  more  likely  to  be  the  precursor  of  cancer 
than  chronic  mastitis  ;  and  since  this  disease  gives  rise  to  cir- 
cumscribed induration,  its  presence  can  hardly  be  overlooked. 
Yet  how  rarely  does  mammary  cancer  ever  appear  to  start  in 
connection  with  such  indurations.  I  have  met  with  this  con- 
junction only  twice  in  137  cases  ;  hence  it  seems  to  me  im- 
probable that  chronic  mastitis  plays  an  important  part  in  the 
genesis  of  mammary  cancer.**'^ 

The  outcome  of  all  this  is  ;  that  intrinsic  causes  are  much 
more  important  factors  in  the  origination  of  cancer  than  extrinsic 
ones,  which  are  by  no  means  its  necessary  antecedents.  In  the 
vast  majority  of  cases  the  outbreak  of  this  disease  appears  to  be 
entirely  spontaneous  ;  that  is  to  say,  it  cannot  be  attributed  to 
the  immediate  action  of  any  appreciable  extrinsic  cause  what- 
ever. 

§   VIII. The  Biological  Distribution  of  Cancer,  &c. 

In  studying  the  etiology  of  malignant*^"  and  other  neoplasms, 


•^  According  to  Gross,  cancer  of  the  breast  appeared  to  develop  out  of  chronic 
inflammatory  induration  in  49  out  of  907  cases,  or  in  5-4  percent. — Internat.  Journal 
Med.  Set.,  Mar.,  1888,  p.  222. 

""  As  I  have  elsewhere  pointed  out  ("  The  Principles  of  Cancer  and  Tumour 
Formation,"  London,  1888,  p.  140),  the  essential  feature  of  malignancy  is  not  auto- 
infectiveness— as  most  pathologists  assume — but  the  indefinitely  sustained  power  of 
certain  cells  to  grow  and  multiply  in  excess  uf  the  normal  requirements. 


BIOLO(nCAL    DISTRIT3UTI0N    OF    CANCER.  299 

it  is  important  to  recollect  that  they  are  not  peculiar  to  mankind, 
nor  even  to  animals.  It  seems  probable,  under  certain  conditions, 
that  such  growths  may  arise  from  any  multicellular  animal  or 
vegetable  being. 

In  a  state  of  nature  these  abnormalities  hardly  ever  occur. 
It  is  exclusively  among  domesticated  varieties,  or  those  that 
have  been  kept  long  in  confinement  that  they  are  met  with. 
Even  under  such  circumstances,  malignant  epithelial  neoplasms 
are  of  very  rare  occurrence  in  the  animal  world,  as  compared 
with  mankind  ;  however,  cases  have  been  met  with  in  most  of 
our  domesticated  animals,  especially  in  horses,^''  dogs  and  cats, 
also  rats  and  mice  in  confinement.  The  mammary  glands  of 
many  female  animals  are  liable  to  be  thus  affected. 

Much  commoner  and  more  widely  diffused  are  the  sarcomas 
which  have  been  met  with  in  nearly  all  classes  of  animals,  from 
fish  upwards  ;  but  they  oftenest  occur  among  ordinary  domesti- 
cated animals,  e.g.,  dog,  horse,  cat,  cow,  common  fowl,  &c.  Male 
dogs,  horses,  asses,  and  pigs  are  particularly  liable  to  sarcoma  of 
the  testis.  Horses — especially  those  of  white  or  grey  colour — 
are  remarkable  for  their  proneness  to  melanotic  sarcoma,  the 
region  of  the  anus  or  tail  being  the  part  usually  affected.  Other 
situations  in  which  melanotic  growths  have  been  observed  in 
these  animals  are  the  vulva,  scapular  region,  skin,  axilla  and 
lungs.  In  the  Hiinterian  Museiivi^^  is  a  specimen  of  melanoma 
of  a  white  cow's  udder.  Horses  are  also  subject  to  psammomas 
of  the  brain. 

According  to  Rayer,  carnivorous  animals  are  more  prone  to 
malignant  disease  than  herbivorous  ones,''°  whereas,  with  regard 
to  tubercle,  the  relative  liability  is  just  the  converse.  In  this 
connection  it  is  noteworthy  that  monkeys  manifest  very  little 
tendency  to  neoplasms,  malignant  or  otherwise ;  and  they  are 
seldom  the  victims  of  tubercle.^^ 


"  For  a  histologically  verified  case   of  epithelioma  of  the  penis  of  a  horse,  by 
Patterson,  vide  Illus.  Med.  Neios,  Dec,  1888,  p.  220. 
*'  No.  469,    Path.  Series. 

'^  For  cases  of  cancer  in  herbivora  by  Burke,  vide  Veterinarian,  Feb.,  1890,  p.  63. 
"'  Sutton,  Lancet,  Aug.,  1883. 


300         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

Fibromas,  enchondromas,  and  osteomas  are  as  common  and 
as  widely  diffused  as  sarcomas. 

Fatty  tumours  are  occasionally  seen  in  domesticated  animals, 
such  as  the  ox,  horse,  sheep,  and  fowl. 

Mammary  fibro-adenomas  of  female  dogs,  cats,  &c.,  are  fairly 
common,  and  enchondromatous  mammary  growths  are  much 
oftener  met  with  in  these  animals  than  in  mankind. 

Cysts  occur  frequently  in  most  domesticated  animals,  their 
commonest  situation,  being  in  the  ovaries. 

That  trees  are  liable  to  be  affected  by  malignant  and  non- 
malignant  neoplasms,  I  have  elsewhere  shown.^^ 

S     IX. Multiple  Primary  Cancers,  and  the  Association  of  Cancer  with  other 

Neoplasms. 

It  is  now  generally  recognised  that  cancer  may  originate 
primarily  from  more  than  a  single  focus.  Pathologists  have 
been  aware  of  this  for  some  time,''^  although  it  is  only  recently 
that  the  subject  has  attracted  special  attention.  Such  cases  are, 
however,  exceedingly  rare.  The  wonder  is  that  they  do  not 
occur  more  frequently,  especially  if,  as  alleged,  cancer  be  a  para- 
sitic disease. 

The  breast  is  no  exception  to  this  rule,  for  the  initial  lesion" 
of  mammary  cancer  is  almost  invariably  solitary.  According  to 
Gross  two  or  more  nodules  are  met  with  as  its  first  obvious  mani- 
festation in  about  3  per  cent,  of  all  cases.  Leopold,^^  examining 
cancerous  breasts  removed  at  early  stages  of  the  disease,  when 
the  lesions  were  quite  small,  almost  invariably  found  local  dis- 
semination. Most  of  these  multiple  nodules  no  doubt  arise  in 
this  way.  In  rare  instances  they  may  be  due  to  the  co-existence 
of  one  or  more  small  fibro-adenomatous,  or  other  non-malignant 
nodules,  with  the  cancerous  tumour,  of  which  examples  have 
been  recorded. 

"^  "The  Principles  of  Cancer  and  Tumour  Fornialion,"  1888,  chap,  iii, 
"'   Q.v.     Virchow,     "  La    Patliologie    des    Tunicurs ;        Broca,     "  Traile    des 
Tumeurs,"  &c. 

"'  Arch.  f.  GyH.,  Bd.  v.,  1873,  S,  405. 


MULTIPLE    PRIMARY    CANCERS.  3OI 

The  hyperplastic  condition  of  the  glandular  epithelia  that 
accompanies  the  outbreak  of  mammary  cancer  maybe  regarded 
as  analogous  to  the  ichthyotic  changes  in  the  buccal  mucous 
membrane,  that  so  often  co-exist  with  cancer  of  the  tongue, 
mouth,  &c.  In  connection  with  these  ichthyotic  areas  of  the 
buccal  region,  independent  outbreaks  of  cancer  have  often  been 
observed  ;  and  it  is  highly  probable  that  hyperplastic  glandular 
elements  in  the  breast  may  occasionally  originate  multiple  can- 
cerous growths  in  like  manner ;  although,  owing  to  the  impos- 
sibility of  certainly  excluding  disseminative  lesions,  this  mode 
of  origin  does  not  here  admit  of  absolute  demonstration.  Nearly 
allied  to  these  independent  outbreaks  are  those  cases  in  which, 
after  operation,  with  freedom  from  recurrence  for  long  periods, 
the  disease  at  length  returns  in  the  vicinity  of  the  primary  lesion, 
owing  to  fresh  outbreaks  arising,  as  Heidenhaim  believes,  from 
proliferating  glandular  elements,  left  behind  at  the  primary 
operation. 

In  no  part  of  the  body  does  the  initial  outbreak  of  cancer  so  frequently 
manifest  itself  in  the  form  of  multiple  foci,  as  in  the  ski7i — especially  the  skin 
of  the  face.  In  these  cases  hyperplastic  changes  of  the  adjacent  integument 
almost  invariably  co-exist.  The  persons  thus  affected  usually  are  workers 
in  tar,  paraffin,  &c.,  as  in  cases  reported  by  Volkmann,  Tillmann,  Schim- 
melbusch,  &c.  In  chimney  sweeps  I  have  seen  the  scrotal  integument 
similai'ly  affected.  Tillmann'-*^  has  met  with  an  instance  of  epithelioma  of 
the  integument  of  the  forearm  and  of  the  scrotum^  in  a  paraffin  worker.  In 
old  persons,  multiple  cutaneous  cancers  sometimes  arise  in  connection  with 
chronic  seborrhoea.  Primary  multiplicity  is  also  often  seen  in  cases  of  rodent 
ulcer,  especially  in  aged  subjects.  It  will  be  noticed  that  in  most  of  the 
cases  just  mentioned,  the  outbreak  of  the  disease  appears  to  have  arisen  in 
connection  with  some  form  of  chronic  irritation. 

Cancer  may  also  spring  up  as  a  primary  disease  in  more  than 
one  part  or  tissue  of  the  body,  although  such  coincidences  are 
of  the  greatest  rarity. 

In  certain  cases  of  acute  diffuse  mammary  cancer,  both 
breasts    may    be    simultaneously    invaded,   of  which    examples 


^^  Deutsche  Zeitschr.  f.  Chir.,  Bd.  xiii.,  1880. 


302         GENERAL    I'ATHOLOCJY    OF    MAMMARY    CANCER. 

have   been    recorded    by    Billroth,^^    Aitken,^^    Klotz,^^    Volk- 

mann,^^  and  others. 

A  similar  state  of  things  is  occasionally  met  with  in  other  paired  organs, 
such  as  the  testes  and  ovaries  ;  and  Mandry'""  has  recorded  an  instance  of 
symmetrical  cancer  of  both  legs,  and  another  of  both  ears.  Of  263  cases 
of  primary  cancer  of  the  extremities,  analysed  by  Michael,  two  were 
symmetrical. 

It  is  by  no  means  rare  to  see  cancer  of  one  breast  followed, 
after  a  time,  by  outbreak  of  the  disease  in  the  other.  The  great 
majority  of  these  cases  are,  however,  due  to  direct  extension  of 
the  primary  disease,  or  to  its  dissemination.  Yet  it  occasionally 
springs  up  independently  in  the  opposite  breast,  as  in  the  fol- 
lowing case. 

(i)  An  unmarried  woman,  aged  60,  twenty-one  months  before  I  saw  her, 
first  noticed  a  hard  lump,  the  size  of  a  Brazil  nut,  in  the  middle  of  her  left 
breast  ;  four  months  later  a  similar  lump  was  discovered  in  the  middle  of 
her  right  breast.  When  she  came  under  my  observation  the  central  part  of 
each  breast  was  occupied  by  a  large  hard  tumour,  to  which  the  overlying 
purplish  skin  was  adherent,  and  both  nipples  were  retracted,  and  the  glands 
in  both  axillje  enlarged.  Her  face  had  a  peculiar  pinched  expression,  and 
she  was  very  emaciated,  but  not  sallow.  She  died  of  asthenia  ninety-nine 
days  later,  without  having  undergone  any  operative  treatment.  At  the 
necropsy,  the  cancerous  growths  in  each  breast  were  found  to  have  increased 
somewhat  in  size,  but  neither  had  ulcerated.  Both  were  extensively  adherent 
to  the  overlying  skin  and  to  the  subjacent  structures.  The  glands  in  both 
axillae  were  cancerous,  and  the  liver  contained  a  cancerous  nodule  the  size  of 
a  pea,  and  four  small  angiomatous  growths. 

The  three  subjoined  cases  evidently  belong  also  to  the  same 
category. 

(i)  A  patient  seen  by  Bucher,^"'  having  remained  free  from  any  return  of 
the  disease  for  six  years,  after  amputation  of  one  breast  for  cancer,  then 
found  the  disease  spring  up  in  the  other  breast. 

(2)  '"'  A  woman,  aged  48,  under  Bryant's  care  with  cancer  of  the  right 
breast,  without  obvious  disease  of  the  axillary  glands.  Ten  years  previously 
her  left  breast  had  been  amputated  for  similar  disease.     The  right  breast 

■"''Deutsche  Chir.,  Lief  41,  .S.  128. 

'"  Med.  Times  and  Gaz.,  1859,  vol    i.,  p.  357. 

m  <i  Ueber  Mastitis  Carcinomatosa,"  &c. ,  L  D.     Halle,  1869. 

™  Beilr.  2.  klin.  Chir.,  1875,  .S.  310. 

""'  Beitr.  z.  klin.  Chir.,  1S92. 

""  Zeigler's  Beitr.  2.  path  Anat.,  Bd.  xiv.,  S.  74. 

102  ««  Diseases  of  the  Breast,"  1887,  pp.  213  and  221. 


MULTIPLE    PRIMARY    CANCERS.  3O3 

was  now  amputated.     Three  years  later,  when  last  heard  of,  the  patient  was 
well  and  free  from  any  return  of  the  disease. 

(3)  The  patient,  aged  60,  when  first  seen  by  Bryant  had  scirrhous  cancer 
of  her  right  breast  of  eight  months'  duration,  there  being  no  disease  of 
the  axillary  glands.  Two  years  and  a-half  previously  her  left  breast  had 
been  amputated  for  ulcerated  cancer  of  several  years'  duration,  but  which 
had  not  affected  the  axillary  glands.  The  right  breast  was  now  ampu- 
tated, without  opening  the  axilla.  She  soon  recovered,  and  was  free  from 
recurrence  when  last  heard  of  eighteen  months  later. 

Nunn,^*^^  has  recorded  an  instance  of  tubular  cancer  (with 
cysts)  of  the  left  breast,  co-existent  with  atrophic  acinous  cancer 
of  the  right  breast. 

The  patient  was  a  lady,  aged  57,  in  whose  left  breast — near  the  nipple — 
a  small  tumour  was  first  noticed  six  years  previously.  This  gradually 
increased  to  a  large  size,  and  was  associated  with  occasional  sanious  dis- 
charge from  the  nipple.  There  was  no  enlargement  of  the  axillary  glands. 
The  affected  breast  was  amputated.  The  tumour  consisted  chiefly  of  one 
large  thin-walled  cyst,  with  a  few  nodules  the  size  of  hemp  seeds  projecting 
into  the  cavity.  These,  on  microscopical  examination,  presented  the  ap- 
pearance of  tubular  cancer.  She  remained  well  after  the  operation  for  three 
years,  when  her  health  began  to  fail,  without  any  obvious  cause.  In  the 
course  of  medical  examination  of  the  chest,  atrophic  acinous  cancer  of  the 
right  \>x&2l%\. — which  she  had  hitherto  carefully  concealed — was  accidentally 
discovered.  She  died  of  this  disease  a  few  months  later.  There  was  no 
necropsy. 

The  following  somewhat  similar  case  by  Mandry/"*  is  of 
interest. 

A  multipara,  aged  43,  in  whose  right  breast  was  a  cancerous  tumour — the 
size  of  an  apple — of  four  months'  duration.  It  was  adherent  to  the  pectoral 
muscle,  and  the  axillary  glands  were  enlarged.  The  breast  was  extirpated, 
together  with  the  pectoral  muscle  and  the  axillary  glands.  Histologically 
the  tumour  proved  to  be  ordinary  acinous  (scirrhous)  cancer.  Three  months 
and  a-half  later,  recurrence  was  first  noticed  in  the  old  cicatrix.  A  fortnight 
previously  a  nodule  had  been  noticed  in  the  left  breast.  The  latter  soon 
increased,  and  the  glands  in  the  left  axilla  enlarged.  The  local  recurrence 
was  then  excised,  the  left  breast  extirpated,  and  the  left  axilla  cleared.  On 
histological  examination  of  the  tumour  in  the  left  breast,  it  proved  to  be 
tubular  cancer. 

Multiple  cancers  situated  in  different  parts  of  the  body  can 
only  be  regarded  as  primary,  when  each  has  developed  from  the 


""  Trans.  Path.  Soc.  Lond.,  vol.   xli. ,  1890,  p.  224. 
""  Beitr.  z.  klin.  Chir.,  1892. 


304         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER, 

epithelium  of  its  own  locality  ;  and  consequently  when  each  has 
usually  different  histological  structure. 

In  the  following  case,  under  my  observation,  a  patient  who 
had  suffered  for  many  years  from  rodent  ulcer  of  the  face,  at 
length  developed  mammary  cancer. 

She  was  a  widow,  aged  ^l,  who,  nine  years  previously,  first  noticed  a 
small  rodent  ulcer  at  the  inner  angle  of  the  left  orbit.  The  disease  pro- 
gressed but  slowly.  After  it  had  lasted  for  seven  years,  hard  cancer  deve- 
loped in  the  left  breast.  The  latter  disease  progressed  rapidly,  and  she  died 
from  it  rather  more  than  two  years  after  its  first  appearance.  No  operation 
was  ever  done  for  either  cancer.  At  the  necropsy  the  left  mammary  region 
was  occupied  by  an  adherent  mass  of  hard,  ulcerated  cancer,  and  the  adjacent 
soft  parts  were  extensively  infiltrated.  The  axillary  glands  were  invaded, 
and  there  were  several  cancerous  nodules  in  the  skin  of  the  left  arm.  The 
rodent  ulcer  was  still  of  no  great  size.  The  left  lung  was  collapsed,  and  its 
apex  was  bound  to  the  chest  wall  by  old  adhesions.  There  was  about  a  pint 
of  blood-stained  watery  fluid  in  the  pleural  cavity.  The  right  lung  was 
emphysematous.  The  liver  was  atrophied,  and  the  gall  bladder  full  of 
calculi.  The  right  kidney  was  also  atrophied,  and  its  pelvis  contained  a 
large  calculus.  Several  fibro-myomatous  tumours  were  connected  with  the 
uterus,  one — the  size  of  a  duck's  ^g<g — was  calcified. 

Hutchinson^*^^  says  he  has  several  times  seen  similar  coinci- 
dences, but  he  gives  hardly  any  details. 

In  one  case,  the  patient,  who  had  suffered  long  from  Paget's  disease  of 
the  nipple  and  cancer  of  the  breast,  had  also  a  rode?tt  ulcer  of  the  left 
eyebrow. 

The  three  following  somewhat  similar  coincidences  were 
observed  by  Bryant  :  ^^" — 

(i)  A  widow,  aged  74,  had  atrophic  cancer  of  the  right  breast  of  twenty- 
six  years'  duration,  that  had  been  ulcerated  for  thirteen  years.  Epithelioma 
of  the  nose  then  supervened,  the  breast  cancer  having  remained  nearly 
stationary  for  many  years. 

(2)  A  childless,  married  woman,  aged  63,  had  epithelial  cancer  of  her 
nose  excised.  Five  years  later  she  came  under  observation  again,  with  hard 
cancer  of  her  right  breast  of  eight  months'  duration,  of  which  she  died  two 
years  later.     There  was  no  return  of  the  nasal  cancer. 

(3)  A  thin,  feeble  woman,  aged  60,  with  an  ulcerated  scirrhous  cancer  of 
the  central  part  of  the  left  breast  of  eight  or  nine  years'  duration.  During 
the  last  five  years  there  had  been  increasing  difficulty  in  swallowing,  and 
for  some  months  she  had  only  been  able  to  take  fluids.     Stricture  of  the 


loj  «<  Archives  of  Surgery,"  vol.  ill.,  No.  9,  p.  47. 
iiw  >(  Diseases  of  the  Breast,"  1887,  p.  340. 


MULTIPLE    PRIMARY    CANCERS.  305 

oesophaf^iis  was  discovered — passable  only  by  the  smallest  bougie — which 
had  every  appearance  of  being  cancerous. 

Panas'"'  mentions  having  seen  cancer  of  the  breast  in  a  inatt,  aged  65, 
from  whom  Velpeau  had  excised  an  epithelioma  of  the  lip,  fifteen  years 
previously  ;  and  Graviller'"'*  has  met  with  a  case  of  cancer  of  the  male 
breast  associated  with  epithelial  cancer  of  the  lip. 

Dobson'""  had  a  patient  with  a  primary  cancer  of  the  breast,  who 
remained  well  and  free  from  any  return  of  the  disease  for  six  years  after  its 
amputation,  when  epithelial  cancer  of  the  tongue  supervened,  of  which  she 
soon  died. 

In  a  woman  rather  over  60,  Michelshon""  met  with  hard  cancer  of  the 
right  breast  and  cutaneous  epithelioma  of  the  right  ala  nasi. 

The  following  cases  illustrate  the  independent  outbreak  of 

the  disease  in  the  breast  and  uterus. 

Broca'"  has  recorded  an  instance  in  which,  after  mammary  caneer  had 
existed  for  two  and  a-half  years,  the  cervix  uteri  became  cancerous.  Six 
months  later  no  sign  of  cancer  had  appeared  elsewhere.  The  uterine 
disease  here  presented  every  indication  of  being  of  independent  origin. 

Mercanton^^^  reports  the  three  following  examples  : — 
(i)  A  woman,  aged  48,  with  hard  cancer  of  the  right  breast  and  secondary 
disease  of  the  axillary  glands.  The  diseased  breast  was  extirpated,  and  the 
axilla  cleared.  About  nine  weeks  later  cancer  of  the  cervix  tcteri  was  dis- 
covered and  excised.  About  eight  months  after  the  mammary  extirpation, 
the  disease  had  recurred  in  sitil  and  in  the  axilla  ;  it  was  again  removed 
from  these  situations.  Six  months  later  she  came  under  treatment  again 
with  further  recurrence  in  the  right  mammary  region,  and  in  the  left  breast. 
These  were  removed  by  operation,  and  a  month  later  secondarily  diseased 
glands  were  removed  from  the  left  axilla.  About  this  time  there  was  noticed 
free  discharge  from  the  vagina  ;  on  examination  the  uterus  was  found  to  be 
fixed,  and  the  cervix  infiltrated  with  hard  cancerous  growth.  Six  months 
after  the  last  mammary  operation  there  was  extensive  recurrence  in  both 
pectoral  regions,  and  in  both  axillce. 

(2)  In  a  patient  48  years  of  age,  there  was  a  hard  cancerous  tumour  in 
the  left  breast  of  two  years'  growth.  It  was  adherent  to  the  overlying  skin, 
and  the  axillary  glands  were  invaded.  Th&  portio  vaginalis  uteri  was  re- 
placed by  a  large,  fungating,  hsemorrhagic  cancerous  outgrowth. 

(3)  A  woman,  aged  51,  in  1889,  became  subject  to  pain  in  defseca- 
tion.     In  the  summer  of  1890  induration  in  the  left  breast  was  noticed.     In 

'""  Cited  by  Poirier,  "  Tumeurs  du  Sein  chez  rhomme,"  Paris,  1883,  p.  98. 
'"*  Canada  Medical  and  Surgical  Journal,  Montreal,    1873,  i.,  p.  271. 
^"'■^  Bristol  Med.   Chir.  Journal,  Dec,  1889. 

""  "Zur  Multiplicitat  der  prim'aren  Carcinomen,"  I.D.,  Berlin,  1889. 
'"  "  Traite  des  Tumeurs,"  t.  i.,  1866,  p.  284. 

"- "  Des  Carcinomes  primaires  multiples,"  Rev.  Med.  de  la  Suisse  Roniande,  No. 
3,  1893,  P-  173- 
20 


306         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

November  of  the  same  year  she  was  found,  on  examination,  to  have  cancer 
of  the  breast,  and  cancer  of  the  corpus  uteri. 

As  instances  of  associated  mammary  and  ovarian  cancer,  in 
which  each  neoplasm  probably  originated  independently,  the 
following  cases  are  interesting. 

(i)  "*The  patient,  aged  53,  the  mother  of  two  children,  came  under 
observation  on  account  of  a  left  ovarian  tumour,  with  symptoms  of  one 
year's  duration.  During  this  period  she  had  been  tapped  nine  times.  A 
multilocular  cystic  cancer  of  the  left  ovary  was  removed  by  laparotomy. 
She  made  a  good  recovery.  About  nine  months  later  she  again  came 
under  treatment  with  a  cancerous  neoplasm  of  a  year's  growth  in  her  left 
breast.,  and  enlarged  axillary  glands.  For  twenty-one  years  she  had  been 
aware  of  the  existence  in  the  diseased  breast  of  a  hard,  indolent,  stationary 
tumour,  the  size  of  a  hazel  nut,  and  the  present  tumour  seemed  to  grow  in 
connection  with  this.  The  breast  was  extirpated,  and  the  axillary  glands 
removed.  Recurrence  in  the  mammary  region  soon  afterwards  set  in,  and 
was  extirpated.  Seven  months  later  there  were  further  recurrences  in  the 
pectoral  region,  and  ascites  developed,  with  nodular  masses  disseminated 
in  the  abdomen.  Finally,  double  pleural  effusion  supervened,  of  which  she 
died.     There  was  no  necropsy. 

(2)  In  Mercanton's  case  the  patient  was  an  unmarried  peasant,  aged  47, 
who  had  suffered  from  uterine  prolapse  for  four  years.  Not  the  least  inter- 
esting feature  in  her  case  is  the  extraordinary  series  of  operations  she 
underwent  in  the  course  of  a  few  years,  which  must,  I  should  think,  be 
unique,  even  in  continental  experience.  For  the  prolapse  the  following 
operations  were  done  : — anterior  kolporrhaphy  with  perinaso-plasty,  Alexan- 
der's operation,  excision  of  the  portio.,  and  extirpation  of  the  vaginal  mucous 
membrane.  Prolapse  of  the  anus  having  supervened  twelve  months  after 
the  first  of  these  operations,  the  actual  cautery  was  applied  to  the  recto-anal 
region.  While  this  lesion  was  healing,  fourteen  months  after  admission,  a 
hard  nodule,  the  size  of  a  nut,  was  noticed  in  the  inferior  and  axillary 
region  of  the  left  breast.,  with  enlarged  axillary  glands.  For  this  the 
breast  was  extirpated  and  the  axilla  cleared,  sixteen  months  after  her  ad- 
mission into  hospital.  On  histological  examination  the  tumour  proved  to 
be  acinous  cancer.  The  uterine  prolapse  having  returned,  a  further  opera- 
tion, hystero-plexy,  was  done  for  it.  She  soon  recovered,  and  left  the 
hospital  in  good  health  a  month  later.  She  returned  three  months  after- 
wards with  a  left  ovarian  tumour.  For  this  laparotomy  was  done,  and  both 
ovaries  being  found  affected  with  soft  cystic  cancer,  they  were  removed.  A 
few  months  later  she  left  the  hospital  convalescent.  Two  and  a-half  years 
later  she  again  came  under  treatment  with  an  intra-abdominal  tumour  of 
the  left  sacro-iliac  region.  Laparotomy  was  again  performed,  when  the 
sigmoid  and  rectum  were  found  embedded  in  a  hard  mass  of  cancerous 
growth,  and  the  peritoneum  was  infiltrated.     Under  these  circumstances  an 


Poupinel,  Aiin.  de  Gyn.,  Jan.,  1890. 


MULTIPLE    PRIMARY    CANCERS.  307 

artificial  anus  was  established  at  the  abdominal  wound.  From  the  opera- 
tion this  poor  peasant  woman  again  recovered,  but  subsequently  she  suc- 
cumbed to  the  disease. 

Primitively  multiple  cancerous  growths  have  been  met  with 
in  a  variety  of  situations,  other  than  those  associated  with  breast 
cancer,  as  in  the  following  typical  examples  : — 

Several  instances  of  uterine  and  ovarian  cancer  thus  arising  have  been 
reported  by  Reichel  and  others. 

In  a  woman,  aged  53,  Mercanton  found  the  disease  affecting  the  uterus 
and  vulva. 

In  a  man,  aged  74,  Beck  met  with  cancer  of  the  pyloric  part  of  the 
stomach  developed  from  the  mucous  glands,  and  colloid  cancer  of  the 
ccecuin.,  developed  from  Lieberkiihn's  follicles. 

Abesser  has  reported  an  instance  of  squamous  epithelioma  of  the  tongue, 
with  colloid,  cylinder-celled  cancer  oi  the.  jejtmwn. 

Bard  has  seen  squamous  epithelioma  of  the  uterus,  associated  in  the 
same  person  with  cylinder-celled  cancer  of  the  head  of  the  pancreas ;  and 
Beck  found  the  same  variety  of  uterine  cancer  co-existing  with  cylinder- 
celled  cancer  of  the  sigmoid  flexure  of  the  colon. 

Kaufmann  excised  a  squamous  epithelioma  of  the  upper  eyelid,  from  a 
man  who  died  six  months  later  of  cylinder-celled  cancer  of  the  rectum. 

Squamous  epithelioma  of  the  vulva,  and  cylinder-celled  cancer  of  the 
colofi,  co-existed  in  Chiari's  patient  ;  and  cancer  of  bladder  and  stomach  in 
Szumann's. 

Schimmelbusch  mentions  having  met  with  a  case  in  which  squamous 
epithelioma  of  the  ear  was  associated  with  similar  disease  of  the  loiver  lip ; 
and  a  man  was  under  Billroth's  care  with  cancer  of  the  stomach,  whose  ear 
had  previously  been  excised  for  epithelial  cancer. 

As  examples  of  the  co-existence  of  mammary  cancer  with 
sarcoma,  I  can  cite  the  following  cases  :  — 

(i)  A  married  won:ian,"^  aged  55,  the  mother  of  seven  children,  six  years 
ago  first  noticed  a  small  lump  in  the  left  breast,  which  made  little  progress 
until  four  months  ago,  since  when  it  had  rapidly  increased.  When  she  came 
under  treatment  this  breast  was  occupied  by  a  mobile,  elastic,  nodular 
tumour,  II  by  10  inches;  but  there  was  no  enlargement  of  the  axillary 
glands.  At  the  same  time  the  right  breast  was  the  seat  of  a  typical 
scirrhous  caiicer  of  one  and  a-half  year's  growth,  the  nipple  being  retracted 
and  the  axillary  glands  enlarged.  The  left  breast  was  amputated,  and  the 
patient  made  a  good  recovery  without  recurrence  ;  but  she  died  two  and 
a-half  years  later  from  the  cancerous  affection  of  the  right  breast.  On 
histological  examination,  the  excised  mammary  tumour  proved  to  be  a  small 
round  and  spindle-celled  adeno-sarcoma. 

'"  De  Morgan,  Trans.  Path.  Soc,  Loud.,  vol.  xix.,  p.  394. 


308         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

(2)  Billroth  "•''  has  reported  a  remarkable  instance  of  cystic  sarcoma  of 
the  left  breast — locally  recurrent  after  amputation,  the  axillary  glands  being 
unaffected — in  which,  a  little  later,  cancer  of  the  right  breast  supervened, 
with  secondary  affection  of  the  axillary  glands,  and  death  from  internal 
dissemination. 

(3)  Some  time  ago  a  case  was  brought  before  the  Clinical  Society  by 
Kesteven,'"^  in  which  six  years  after  extirpation  of  recurrent  mammary 
cancer^  without  any  local  return  of  the  disease,  the  patient  developed  cancer 
of  the  rectitm  and  sarcoma  of  the  femitr,  of  which  she  subsequently  died. 

(4)  A  healthy-looking  woman,  aged  64,  consulted  Bryant  "''  for  a  smooth, 
ovoid,  elastic  tumour,  the  size  of  a  cocoanut,  which  occupied  the  right 
mammary  region.  It  was  of  eight  months'  growth.  In  the  left  breast  was 
an  atrophic  scirrhus  which  had  existed  for  sixteen  years.  Over  the  left  hip 
was  ?L  fatty  tumour^  the  size  of  the  fist,  of  twenty-five  years'  duration.  The 
right  breast  was  amputated,  and  upon  examination  after  removal  the  growth 
proved  to  be  a  mixed-celled  sarcoma^  in  which  spindle  cells  predominated. 
Recurrence  at  the  primary  seat  soon  set  in,  and  after  another  operation 
there  was  likewise  speedy  recurrence,  and  so  on  for  the  next  four  and  a-half 
years,  during  which  time  sixteen  operations  were  performed.  She  was  then 
still  in  good  health,  and  the  cancer  of  the  left  breast  continued  unprogressive. 

(5)  A  multipara,  aged  50,  whose  left  breast  was  amputated  by  the  same 
surgeon  for  cancer  of  two  years'  duration,  four  years  later  had  melanotic 
sarcoma  develop  in  a  mole  of  the  skin  of  the  left  axilla.  In  the  course  of  six 
months  this  increased  to  the  size  of  a  hazel  nut,  when  it  was  excised  and 
never  returned.  There  was  no  recurrence  of  the  original  cancerous  disease 
until  more  than  eight  years  after  the  operation,  when  it  reappeared  in  the 
mammary  region  and  elsewhere,  and  caused  the  patient's  death  some 
months  later. 

(6)  In  another  case,  also  under  the  same  surgeon,  a  single  woman  aged 
40,  had  an  ulcerating  melanotic  sarcoma,  the  size  of  an  orclnge,  in  the 
right  axilla.  It  originated  there,  in  a  cutaneous  mole,  two  years  previously. 
The  patient  remained  well  for  nearly  four  years  after  its  excision,  when  the 
breast  of  the  same  side  began  to  enlarge.  Six  months  later  a  cancerous 
o^roivth  was  found  there.  The  scar  of  the  old  operation  was  sound,  and  free 
from  recurrence.  The  breast  was  amputated  ;  and  eight  years  later  the 
patient  was  in  good  health  and  free  from  any  return  of  either  disease. 

(7)  Two  years  after  amputation  of  the  breast  for  primary  cancer — of 
which  there  was  no  return — a  patient  of  Dobson's  "''  developed  small  round- 
celled  sarcoma  of  the  tonsil. 

Guende"'^  has  met  with  sarcoma  of  the  choroid  developed  in  a  woman 
the  subject  of  inammary  cancer. 


"5  Chir.  Klin.   IVien.,  1868,  S.  66. 

"*  Lancet.,  vol.  i. ,  1876,  p.  315  ;    Clin.  Soc.  Trans.,  vol.  vi.  and  ix. 

"'  "  Diseases  of  the  Breast,"  p.  335. 

""  Bristol  Med.  Chir.  Journal,  Dec,  1889. 

"*  Marseille  Mai.,  No.  7,  1890,  p.  422. 


MULTIPLE    PRIMARY    CANCERS.  3O9 

As  examples  of  cancer  and  sarcoma  co-existing  in  the  same 
person,  elsewhere  than  in  the  breast,  the  following  cases  will 
suffice. 

An  elderly  lady,  one  of  whose  eyes  had  been  excised  by  Hutchinson'-"  for 
melanotic  sarcoma,  died,  free  from  any  return  of  the  original  disease  ten 
years  afterwards,  of  cancer  0/ the  uterus. 

A  man,  aged  52,  under  treatment  at  the  Middlesex  Hospital  for  rodent 
cancer  of  tJie  face,  had  sixteen  years  previously  undergone  excision  of  epithe- 
lioma of  the  loiver  lip,  of  which  there  had  been  no  return. 

Langton'-'  reports  the  case  of  a  man,  aged  46,  with  rodeftt  ulcer  of  twelve 
years'  duration,  just  below  the  lower  eyelid,  which  was  first  excised  two 
years  after  its  appearance,  but  recurred  six  years  later,  when  it  was  again 
removed.  Two  years  later  it  re-appeared  for  the  third  time,  and  again 
recurred  a  few  months  after  removal.  About  this  time  signs  of  a  growth 
within  the  antrum  became  obvious.  The  superior  maxilla  was  excised, 
together  with  the  overlying  skin  and  the  rodent  ulcer.  The  patient  left  the 
hospital  free  from  any  return  of  the  disease,  after  rapid  convalescence.  The 
growth  within  the  antrum  proved  to  be  sarcomatous. 

Cutler^"'  has  met  with  sarcoma  of  the  ovary  co-existing  with  cancer  of 
various  thoracic  aiid  abdominal  organs. 

Following  the  example  of  Virchow,^^^  some  pathologists 
admit  the  existence  of  mixed  malignant  neoplasms,  forms  in 
which  the  sarcomatous  and  carcinomatous  processes  go  on 
simultaneously.  The  histological  characters  of  certain  rare 
new  growths  seem  to  countenance  this  view;  but  never  have 
transitions  from  one  species  of  malignant  new  formation  to 
another  been  verified. 

Of  the  various  non-malignant  neoplasms — not  of  the  breast 
— met  with  in  patients  having  mammary  cancer,  I  have  found 
uterine  fibro-myomas  and  soft  polypi  by  far  the  commonest.  Of 
44  consecutive  necropsies,  the  former  were  present  in  5,  and 
in  3  of  these  cases  there  were  soft  polypi  as  well.^-* 

Next  in  frequency  to  these  ovarian  cystomata  come,  of  which 
there  were  three  examples  in  the  44  necropsies,  one  each  as 
follows — dermoid,  parovarian  and  ovarian. 

''■^''  Archives  of  Stirgery,  vol.  iii.,  No.  9,  p.  48. 
'■-'  St.  Bart.'s  Hasp.  Rep.,  vol.  xxiv.,  1888,  p.  284. 
^'"Boston  Medical  Journal,  Oct.  6,  1892. 
'-^  Path,  des  Tumeurs,  t.  ii.,  1869,  p.  178. 

'-*  Of  123  similar  necropsies  tabulated  by  Nunn,  uterine  fibro-myomas  were 
present  in  20.3  per  cent. 


310        GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

In  this  connection  the  following  case  is  of  interest  : — 

A  single  woman,  aged  56,  came  under  my  observation  with  scirrhous 
cancer  of  the  right  breast,  and  a  few  enlarged  axillary  glands.  In  the  left 
iliac  region  there  was  also  an  ovarian  tumour,  the  size  of  a  man's  fist.  The 
breast  was  amputated  and  the  axilla  cleared.  She  was  soon  convalescent. 
Shortly  afterwards  a  multilocular  cystoma  of  the  left  ovary  was  removed  by 
laparotomy.  There  was  no  sign  of  malignant  disease  in  connection  with  it. 
She  had  completely  recovered  six  weeks  later.'-'' 

Of  86  consecutive  cases  of  mammary  cancer,  I  (ound  /atty 

tumours  present  in  two,  as  under : — 

(i)  A  spare  woman,  aged  85,  with  ulcerated  hard  cancer  of  the  right 
breast  of  one  year's  duration.  She  had  also  a  subcutaneous  lipoma  (3  in.  by 
2  in.)  over  the  right  deltoid  muscle,  and  at  the  upper  and  outer  part  of  the 
right  thigh  a  pendulous  niolliiscum  fibrosuni^  the  size  of  a  bantam's  ^g'g^  and 
several  smaller  ones  at  the  back  of  the  neck.  After  death  she  was  found  to 
have  also  a  dermoid  cyst  of  the  left  ovary,  and  a  soft  polypus  of  the  cervix 
uteri. 

(2)  An  obese  woman,  aged  55,  with  large  pendulous  mammas.  The  right 
one  contains  a  cancerous  tumour,  the  size  of  a  turnip,  of  one  year's  duration. 
At  the  upper  part  of  the  left  thigh,  on  its  inner  side,  is  a  subcutaneous  lipoma 
of  fourteen  years'  growth,  the  size  of  a  man's  hand. 

Hutchinson^^*^  mentions  the  case  of  a  woman  who,  having 
suffered  for  many  years  from  morphosa  of  the  side  of  the  trunk 
and  neck,  at  length  developed  hard  cancer  of  the  breast,  for 
which  she  had  undergone  several  operations.  When  last  seen 
most  of  the  morphoea  patches  had  disappeared. 

In  the  Hunterian  Museuvi}^'^  is  a  specimen  of  hard  cancer  of 
the  breast  associated  with  warty  excrescences  of  the  overlying 
skin. 

§    X. The  Question  of  the  Origin  of  Malignant  from  Non-Malignant  Neoplasms. 

Important  practical  issues  are  involved  in  the  solution  of  the 
question  as  to  the  alleged  liability  of  non-malignant  neoplasms 
to  become  malignant.  If  any  such  tendency  really  exist,  then 
these  neoplasms  ought   to  be  extirpated  as  soon   as  possible. 


'-^  A  similar  case  is  reported  in  St.  Bart's  Hosp.  Reps.,  vol.  xxvii.,  1891,  p.  62  ; 
and  another  in  Ann.  de  Gyn.,  t.  xxxiii.,  1890,  p.  35. 
'-"  Archives  of  Surgery,  Jnly,  1 89 1,  p.  43. 
'-'  No.  4819  of  the  i'alholoj;ical  Series,  q.v.  Pathological  Catalogue,  vol.  iv. 


MALIGNANT    FROM    NON-MALIGNANT    NEOPLASMS.       3II 

Widely  divergent  opinions  have  been  expressed  on  this  subject. 
It  was  formerly  believed  that  every  chronic  tumour  of  the  breast 
either  was  malignant  or  tended  to  become  so.  After  the  non- 
malignant  neoplasms  had  been  clearly  differentiated  from  the 
malignant  ones  by  Astley  Cooper,  the  partisans  of  the  old  belief 
still  maintained  that  the  latter  commonly  developed  from  the 
former.  Cooper  himself  admitted  the  possibility  of  such  an 
occurrence.  He  says/^^"  I  believe  that  if  a  person  has  a  tumour 
of  the  breast  which  is  not  malignant,  and  that  it  remains  so  till 
the  change  of  life  takes  place,  that  then  an  undue  action  may  be 
excited  in  the  part,  and  the  tumour  become  scirrhous." 

Since  innocent  neoplasms  may  inflame,  suppurate,  ulcerate, 
necrose  and  degenerate  just  like  physiological  parts  of  the  body, 
it  seems  not  unreasonable  to  suppose,  on  d  priori  grounds,  that 
they  may  also  become  the  seats  of  malignant  disease.  The 
occasional  co-existence  in  the  same  breast  of  benign  and  malig- 
nant neoplasms  favours  this  view.  Such  are  the  chief  reasons 
which  have  given  rise  to  the  common  belief,  that  innocent 
tumours  are  peculiarly  apt  to  become  malignant. 

On  critical  examination  of  the  subject  two  considerations 
have  much  impressed  me.  The  first  is  the  extreme  rarity  with 
which  these  two  kinds  of  neoplasms  co-exist  in  the  same  breast. 
Of  254  consecutive  cases  of  mammary  cancer,  of  which  I  have 
made  a  detailed  examination,  the  disease  was  associated  with 
fibro-adenoma  in  only  two.  In  other  words,  for  every  case  of 
cancer,  that  had  originated  under  circumstances  suggestive  of 
the  possibility  of  its  having  sprung  from  a  fibro-adenoma,  there 
were  126  cases  that  had  evidently  originated  otherwise.  But 
the  relative  frequency  with  which  fibro-adenomatous  and  can- 
cerous neoplasms  arise  in  the  female  breast  is,  as  I  have  else- 
where shown,^^''  as  372  to  1 863,  or  the  proportion  is  i  to  5.  Hence, 
even  if  we  admit  that  malignant  transformation   takes  place  in 


'-'  "Lectures  on  Surgery,"  1839,  p.  378. 

'-■'  "The  Initial  Seats  of  Neoplasms  and  their  Relative  Frequency." — Annals  of 
Sufgery,  October,  iSgj  ;  also  ch.  vii.,  p.  130. 


312         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

all  such  associated  neoplasms,  the  event  must  be  one  of  extreme 
rarity  ;  very  much  rarer  than  it  would  be  if  fibro-adenomatous 
neoplasms  were  especially  prone  to  become  cancerous.  The 
second  consideration  is,  the  inconclusiveness  of  the  evidence  as 
to  the  malignant  growths  in  most  of  these  cases,  having  sprung 
from  their  non-malignant  associates.  In  many  instances  it  is 
perfectly  evident  that  the  association  is  a  mere  coincidence,  each 
neoplasm  having  originated  from  the  gland  independently. 

Paget""  refers  to  an  example  of  this  kind,  in  which  there  was  found  in 
the  breast  excised  from  a  woman,  aged  32,  a  small  fibro-adenoma  that  had 
existed  for  four  years,  and  far  apart  from  it  a  hard  cancer  of  four  months' 
duration. 

In  a  case  under  Bryant's''"  care,  a  scirrhous  tumour  occupied  the  lower 
and  axillary  part  of  the  right  breast,  while  upon  the  surface  of  the  gland, 
between  the  cancerous  tumour  and  the  nipple,  there  was  a  quite  separate 
encapsuled  fibro  adenoma.     The  patient  was  a  single  woman,  49  years  old. 

Richet  '^-  has  recorded  an  instance  of  two  fibro-adenomata  of  twenty-two 
years'  duration  in  the  lower  segment,  and  cancer  of  recent  growth  in  the 
upper  segment  of  the  same  breast. 

Gross, '^■'  having  enucleated  three  fibro-adenomata  from  the  right  breast 
and  amputated  the  left  for  cancer,  found  that  the  latter  also  contained  three 
fibro-adenomata. 

Waldeyer'^'  met  with  a  cancerous  tumour  associated  in  the  same  breast 
with  eight  fibro-adenomata. 

In  other  cases  the  co-existing  neoplasms  are  more  closely 
associated  ;  but  even  in  these  the  appearance  of  the  non- 
malignant  neoplasms  is  often  such  as  hardly  to  countenance 
the  belief  that  the  malignant  disease  had  sprung  from  them. 

The  two  following  cases  have  come  under  my  observation: — 

(i)  A  well-nourished,  married  woman,  aged  63,  had  a  small,  stationary 
fibro-adenomatous  tumour  in  the  upper  part  of  her  breast  for  thirty-five 
years.  During  the  last  two  months  a  hard  cancerous  growth,  the  size  of  a 
Tangerine  orange,  has  developed  in  connection  with  it.  She  died  a  few 
weeks  later  of  syncope  from  aneurism  of  the  aortic  arch.  On  examination 
of  the  breast  after  death,  it  contained  a  small  circumscribed  encapsuled 
fibro-adenoma,  partially  embedded  in  scirrhous  cancer. 


""  "  Lectures  on  Surgical  Pathology,"  vol.  ii.,  1853,  p.  259. 
131  «<  Diseases  of  the  Breast,"  1887,  p.  339. 
'■'■-  Le  Ptacticien,  No.  14,  1879,  p.  163. 
133  «<  Am.  Syst.  Gyn.,"  vol.  ii.,  p.  207. 
'^'  Arch./,  path.  Ana/.,  Bd.  Iv.,  S.  124. 


MALKJNANT    FROM    NON-MALIGNANT    NEOPLASMS. 


vD'  O 


(2)  A  large,  obese,  sterile,  married  woman,  aged  54,  thirty-four  years 
ago  noticed  a  tumour  in  the  upper  part  of  her  right  breast,  which  slowly 
increased  to  the  size  of  a  hen's  egg  and  then  became  stationary.  So  it 
remained  until  three  months  before  I  first  saw  her,  when,  without  injury  or 
other  known  cause,  the  tumour  began  to  increase.  In  this  short  time  it 
attained  the  size  of  the  foetal  head  at  birth.  On  examination  I  found  a 
circumscribed  bossy  tumour,  adherent  to  the  overlying  skin,  which  was 
reddened  in  places,  but  movable  over  the  subjacent  structures.  Some  of 
the  bosses  were  soft  and  fluctuating,  while  others  were  hard.  The  nipple 
was  retracted.  The  axillary  glands  were  slightly  enlarged,  as  well  as  those 
below  the  clavicle.  There  was  no  history  of  cancer  in  the  family.  The 
breast  was  amputated,  and  the  axillary  glands  removed.  On  examination 
of  the  tumour  after  removal,  the  whole  of  it  was  distinctly  encapsuled.  In 
many  parts  of  the  capsule  there  were  extensive  calcareous  deposits.  On 
section,  the  bulk  of  it  was  seen  to  consist  of  large  cysts,  containing  brown 
serous  fluid,  and  there  were  also  numerous  small  cysts  in  the  adjacent 
parts  ;  in  addition  to  the  fluid  many  of  the  cysts  contained  villous  papillary 
growths.  At  the  sternal  side  of  the  main  tumour  was  a  solid,  yellowish, 
encapsuled  mass,  the  size  of  a  Tangerine  orange,  which  appeared  to  be  of 
more  recent  formation  than  the  rest.  Microscopical  examination  of  a 
portion  of  this  revealed  duct-like  structures,  which  often  contained  papillary 
ingrowths.  Examination  of  the  excised  axillary  glands  revealed  only 
inflammatory  changes.  It  was  evidently  a  case  of  tubular  cancer  that  had 
developed  in  connection  with  cystic  villous  papilloma  of  old  standing.  Two 
and  a-half  months  later  recurrence  was  noticed  in  the  mammary  region. 
Seven  months  later  the  skin  over  the  whole  of  the  front  of  the  thorax  and 
upper  part  of  the  abdomen  contained  numerous  small,  hard,  cancerous 
nodules.  In  the  right  mammary  region  these  were  confluent  and  ulcerated. 
The  right  axilla  was  infiltrated,  and  the  upper  limb  oedematous.  She  died 
of  right  hydrothorax,  with  collapse  of  the  lung,  nearly  seventeen  months 
after  the  operation.  At  the  necropsy  the  local  disease  was  found  to  have 
spread  by  direct  extension  through  the  thoracic  wall  to  the  right  pleura  and 
lung,  both  of  which  contained  numerous  cancerous  nodules.  The  pleural 
sac  contained  70  ounces  of  fluid,  and  the  lung  was  collapsed.  There  were 
two  caseating  tubercular  deposits  in  the  upper  lobe  of  the  left  lung.  The 
heart  was  small  and  fatty.  The  peritoneum  was  thickly  studded  with 
cancerous  nodules.  The  liver  was  large  and  fatty,  and  the  gall  bladder 
contained  three  facetted  calculi.  The  spleen  and  both  kidneys  were  con- 
gested. The  uterus  was  small,  and  presented  several  pedunculated  fibroids 
at  its  fundus. 

Of  cases  observed  by  others  the  following  will  suffice  : — 

(i)  '■■'■' A  lady,  aged  49,  under  Haward's  care,  with  a  firm,  lobulated,  non- 
progressive tumour — the  size  of  a  bantam's  egg — in  the  upper  part  of  her 
right  breast.  After  it  had  remained  in  this  condition  for  nine  years,  a  hard 
nodule  formed  between  the  tumour  and  the  overlying  skin,  which  presented 

'^^  Lancet,  vol,  i. ,  1894,  p.  245. 


314  GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 

all  the  signs  of  cancer.  The  axillary  glands  were  unaffected.  On  histo- 
logical examination  after  extirpation,  the  old  tumour  proved  to  be  a  typical 
fibro-adenoma.  In  the  overlying  skin  was  a  button-like  nodule  of  hard 
cancer,  which  adhered  to  the  adjacent  adenoma,  but  had  only  superficially 
invaded  it.  Eleven  months  after  this  operation  two  small  recurrent  nodules 
appeared  in  the  vicinity  of  the  scar. 

(2)  '•'"'In  an  unmarried  woman,  aged  61,  White  found  a  single  fibro- 
adenoma in  the  left  breast,  and  three  similar  tumours  in  the  right  breast. 
In  close  association  with  one  of  the  latter  an  acinous  cancerous  growth 
had  sprung  up. 

(3)  '•''^  A  woman,  aged  44,  had  noticed  from  girlhood  a  stationary  tumour 
the  size  of  a  cherry,  beneath  the  skin  of  her  left  breast.  Two  years  before 
she  came  under  observation  hard  cancer  started  in  the  vicinity  of  this 
tumour.  When  first  seen  she  had  a  cancerous  mass  there,  adherent  to 
the  overlying  skin.  This  was  excised,  and  some  affected  axillary  glands 
were  removed.  On  examination  of  the  part  after  removal,  a  rounded  fibro- 
adenomatous  tumour  was  found,  completely  embedded  in  scirrhous  cancer, 
which  surrounded  it  to  the  extent  of  from  i  to  ij  inches.  On  microscopical 
examination  it  was  found  that  the  cancerous  disease  had  invaded  the 
structure  of  the  adenoma  ;  but  the  author  is  doubtful  whether  this  implies 
that  it  really  commenced  in  the  tissue  of  the  first  tumour. 

(4)  '^'^The  patient,  50  years  old,  had  a  hard,  painless,  quiescent,  filbert- 
sized  tumour  in  her  left  breast  for  22  years  ;  when  she  was  found  to  be 
suffering  from  an  abdominal  tumour,  which  was  removed  by  laparotomy, 
and  proved  to  be  an  adenoma  of  the  ovary.  Three  months  after  con- 
valescence the  mammary  tumour  became  painful  and  commenced  to  in- 
crease progressively.  A  year  later  it  was  excised,  when  it  proved  to  be 
cancerous,  and  recurred  twice  within  the  two  following  years. 

(5)  '^^  A  single  woman,  aged  65,  whose  mother,  sister,  and  other  relations 
had  died  of  cancer.  Seven  years  ago  she  first  noticed  a  swelling  at  the 
upper  part  of  her  right  breast,  which  subsecjuently  increased  slowly,  until 
three  years  ago,  when  it  began  to  progress  more  rapidly.  When  first  seen 
the  right  breast  was  occupied  by  a  cystic  tumour  the  size  of  the  fcetal  head 
at  birth  ;  at  its  upper  part  a  hard  lump  could  be  felt.  Examination  of  the 
breast  after  removal  revealed  a  large  unilocular  cyst  containing  a  brownish 
fluid,  with  a  cancerous  tumour  (2in.  by  2in.)  in  the  upper  part  of  the  cyst 
wall.  The  central  part  of  this  cancer  had  undergone  calcareous  degenera- 
tion ;  that  part  of  its  surface  which  bulged  into  the  cyst  cavity  presented 
several  polypoid  growths. 

(6)  '■"•  A  farmer's  wife,  aged  42,  married  for  fifteen  years,  but  childless, 
came  under  treatment  with  a  tumour  the  size  of  a  walnut  in  the  upper  part 


"*  Trans.  Path.  Soc.  Loud.,  1892,  p.  120. 

'"  J.  Hutchinson,  jun.,  Trans.  Path.  Soc.  Land.,  vol.  xxxix.,  1888,  p.  315. 

""  G.  Ponpiniel,  Annates  de  Gyn.,  xxxiii.,  1890,  p.  35. 

""  T.  Smith,  Trans.  Path.  .^o.-.  0/ Land.,  vol.  xxii.,  p.  267. 

""  R.  Parker,  //n'd.,  vol.  xxxii.,  p.  233. 


MALIGNANT    FROM    NON-MALIGNANT    NEOPLASMS.       315 

of  her  left  breast,  the  nipple  and  the  axillary  glands  being  normal.  There 
was  some  doubt  as  to  its  nature,  so  an  exploratory  incision  was  made  into 
it,  when,  as  it  looked  just  like  cancer,  the  whole  breast  was  removed.  On 
examination  of  the  part  after  removal  the  breast  was  found  separated  from 
the  fascia  pectoralis  by  a  bursa,  into  the  anterior  wall  of  which  a  nodular 
tumour  projected,  having  all  the  gross  characters  of  ordinary  fibro-adenoma. 
It  was  enveloped  in  a  thick  fibrous  capsule,  with  the  superficial  aspect  of 
which  the  cancerous  growth  that  had  been  incised  at  the  exploratory 
operation,  was  connected.  Histological  examination  showed  that  the 
former  tumour  consisted  of  wavy  fibrous  tissue,  enclosing  acinous  and 
tubular  structures,  and  the  latter  presented  the  appearance  of  ordinary 
acinous  (scirrhous)  cancer. 

(7)  '^^  A  healthy  widow,  aged  30,  with  one  child  10  years  old,  came  under 
observation  having  a  nodular,  elastic,  painless  swelling  in  the  clavicular 
part  of  her  left  breast.  It  was  somewhat  pear-shaped,  with  the  narrow  end 
near  the  nipple,  and  of  seven  months'  duration.  Pressure  caused  a  viscid 
fluid  to  exude  from  the  nipple,  which  was  otherwise  normal.  There  was  no 
enlargement  of  the  axillary  glands.  The  tumour  was  excised,  together  with 
the  adjacent  parts  of  the  breast.  On  examination,  after  removal,  most  of 
the  tumour  was  formed  of  a  cyst  that  communicated  with  a  duct  near  the 
nipple,  and  contained  serous  fluid.  The  surrounding  tissues  contained 
numerous  small  cysts,  with  intra-cystic  villous  growths.  The  patient 
remained  free  from  any  return  of  the  disease  for  eleven  and  a-half  years 
after  the  operation,  when  scirrhous  cancer  developed  in  the  old  cicatrix,  with 
enlargement  of  the  axillary  glands.  For  this  the  breast  was  amputated  and 
the  axilla  cleared  ;  the  patient  making  a  good  recovery. 

Paget^^-  refers  to  a  specimen  in  the  museum  of  St.  Bartholomew's 
Hospital  (Series  xxxiv..  No.  16)  which  shows  a  hard  cancer  arvd  a.  proliferous 
cyst  in  the  breast  of  a  woman  who  died  some  time  after  its  removal,  with 
recurrence  of  the  cancer.  In  this  instance  the  two  neoplasms,  although  co- 
existing in  the  same  breast,  were  nevertheless  quite  distinct. 

Poulsen'^^  has  related  the  history  of  a  man  in  whom  mammary  cancer 
developed  in  connection  with  a  ncevus. 

Many  instances  of  the  development  of  sarcoma  in  association 
with  mammary  fibro-adenoma  have  also  been  recorded.  Labbe 
and  Coyne^**  believe  that  most  sarcomata  of  the  breast  originate 
thus,  rather  than  from  the  tissues  of  the  gland  itself  In  support 
of  this  they  instance  the  following  case,  in  which  an  adeno-cystic 
sarcoma  arose  in  close  connection  with  an  old  adeno-fibroma. 


'"  Bryant,  Op.  cit.,  p.  161. 

'""Lect.  Surg.  Path.,"  vol.  ii.,  1853,  p.  259. 

^^^  Arch.  f.  klin.  Chir.,  xlii.,  1 891,  S.  593. 

lu  <«  Ti-aiie  des  Tumeurs  benignes  du  Sein,"  pp.  290  and  363. 


o 


1 6         GENERAL    PATHOLOGY    OF    MAMMARY    CANCER. 


In  the  left  breast  of  a  woman,  aged  44,  a  hard  tumour,  the  size  and  shape 
of  a  wahiut,  had  existed  without  alteration  for  ten  years  ;  when,  without  any 
known  cause,  it  began  to  enlarge,  and  in  the  course  of  two  years  increased 
to  the  size  of  a  newly-born  child's  head.  It  was  then  removed,  together 
with  the  breast,  and  on  microscopical  examination  it  proved  to  be  a  spindle- 
celled  myx-adeno-sarcoma. 

Of  eight  mammary  sarcomata  examined  by  these  authors, 
no  less  than  4  had  a  similar  history — whence  their  conclusion. 
I  have  not  met  with  such  cases  in  anything  like  so  large  a  pro- 
portion. Of  30  sarcomata  of  the  breast  analysed  by  me  there 
was  only  one  instance  of  this  kind.^*^ 

In  this  case  the  patient,  aged  43,  first  noticed  a  small  hard  lump  in  her 
right  breast  six  years  before  she  came  under  my  observation.  This  lump 
having  remained  stationary  for  over  five  years,  then  began  to  enlarge  during 
pregnancy,  and  in  nine  months'  time  it  attained  the  size  of  a  large  orange. 
On  histological  examination  after  removal,  it  proved  to  be  a  round  and 
spindle-celled  adeno-cystic  sarcoma. 

Probably  many  cases  of  this  kind  really  are  sarcomatous 
from  the  first. 

Under  these  circumstances  I  feel  bound  to  reject  Labbe  and 
Coyne's  conclusion,  which  appears  to  be  based  upon  too 
narrow  an  experience.  In  a  certain  proportion  of  their  cases, 
the  initial  tumours  were  probably  nothing  more  than  overgrown 
supernumerary  mammary  sequestrations.  In  other  instances  the 
initial  slowness  of  growth  was  probably  due  to  the  comparative 
paucity  of  the  incorporated  cellular  elements,  which  subse- 
quently become  more  numerous,  and  may  be,  even  changed  their 
nature.  As  examples  of  similar  conditions  by  other  observers, 
the  following  cases  are  of  interest  : — 

Poulsen'^*^  gives  the  history  of  a  girl  16  years  old,  who — after  a  blow — 
noticed  a  tumour,  the  size  of  a  walnut,  in  her  breast,  at  the  inner  side  of  the 
nipple.  This  remained  stationary  for  nearly  thirty-six  years,  and  then  in 
the  course  of  a  few  years  it  attained  the  size  of  an  orange,  when  it  was 
removed. 

Manignac"^  relates  an  analogous  case  in  which  a  tumour,  the  size  of  a 


"^  Billroth   mentions   having   met   with   two  such    instances,   out   of   19  cases. 
Deutsche  Chir.,  Lief  xli.,  S.  67. 

"«  Arch.f.  klin.  Chir.,  xlii.,  1891,  S.  593. 
'*'  Bull,  de  la  Soc.  Aiiat.,  t.  lii.,  p.  428. 


MALIGNANT    FROM    NON-MALIGNANT    NEOPLASMS.       317 

walnut,  after  having  remained  quiescent  for  fifteen  years,  then  increased  so 
rapidly  as  to  attain  the  size  of  a  double  fist,  in  the  course  of  three  months. 

In  a  case  by  Tillaux'^'*  a  tumour,  the  size  of  an  egg,  that  had  been  quies- 
cent for  eighteen  years,  in  the  course  of  a  few  months  attained  the  size  of  an 
adult  head. 

Gross'''^  extirpated  the  breast  of  a  lady,  aged  65,  for  a  small  spindle- 
celled  sarcoma  of  four  years'  growth,  that  originated  in  connection  with 
a  tumour,  the  size  of  a  chestnut,  of  thirty-six  years'  duration.  When 
removed  the  tumour  was  larger  than  the  foetal  head  at  birth,  and  it  had 
doubled  its  volume  in  the  course  of  the  previous  year.  A  recurrent  nodule 
required  removal  from  the  pectoral  muscle  seven  months  later. 

It  follows  from  what  has  been  stated  that  the  possibility  of 
benign  neoplasms  taking  on  malignant  characters  later  in  life, 
must  be  admitted  ;  but  this  is  a  very  different  thing  from 
admitting  that  such  neoplasms  are  specially  prone  to  develop 
malignant  disease.  This  is  disproved  by  the  extreme  rarity  of 
the  coincidence.  My  investigations  show  that  non-malignant 
mammary  neoplasms  are  less  liable  to  originate  cancer,  than 
are  the  glandular  elements  of  the  breast   itself. 


"^Cordier,  These  de  Paris,  No.  494,  1S80. 
"^  "Am.  Syst.  Gyn.,"  vol.  ii.,  p.  206. 


3i8 


CHAPTER   XL 

The  Varieties  of  Acinous  Cancer. 


§     I . The  Acute  Type. 

Although  cancer  of  the  breast  is  usually  a  chronic  disease, 
yet  certain  cases  occasionally  run  an  acute  course.  Of  these 
the  following  types  may  be  recognised  : — 

(i.)  A  very  rare  diffuse  form — denominated  by  the  French 
cancer  deinblce,  sgiiirrhe  ligueux  en  masse  by  Velpeau,  and  mas- 
titis carcinoinatosa  by  Klotz — in  which  the  whole  of  one  or  both 
breasts  may  be  at  once  involved.  It  arises  suddenly,  pro- 
gresses rapidly,  and  is  often  accompanied  by  inflammatory 
phenomena.  No  special  tumour  is  formed,  but  the  whole 
breast  becomes  enlarged  and  hard,  the  skin  reddened,  oede- 
matous  and  adherent,  and  the  subcutaneous  veins  unduly 
visible.  Verneuil  and  Estlander  found  the  temperature  of  the 
affected  skin  from  \  to  2°  above  the  normal,  and  the  former 
has  demonstrated  in  some  cases  a  veritable  cancerous  fever. 
The  adjacent  lymph  glands  are  usually  soon  invaded,  and  there 
is  general  dissemination  of  the  disease,  with  death  from  acute 
cachexia.  Its  total  duration  seldom  exceeds  a  few  months. 
Most  cases — but  not  all — arise  in  connection  with  pregnancy 
or  lactation. 

As  examples  of  this  form  of  the  disease  the  two  following 
cases  will  suffice  : — 

(a)'  A  thin,  pale  woman,  aged  36,  the  mother  of  seven  children,  was 

'  Billroth,  Th.,  Deutsche  Chir.,  Lief  xli.,  S.  128. 


THE    ACUTE    TYPE.  3I9 

admitted  into  hospital  when  near  the  full  term  for  her  eighth  confinement, 
with  both  breasts  larger  than  a  child's  head,  hard,  and  firmly  adherent  to  the 
chest  wall  and  to  the  over-lying  skin.  The  latter  was  tense,  shiny,  con- 
gested and  marbled  by  bluish  veins.  The  breasts  gave  no  milk  or  colos- 
trum. There  was  no  obvious  disease  of  the  axillary  glands.  The  history 
she  gave  was,  that  five  weeks  previously  hardness  set  in  at  the  periphery 
of  both  breasts,  which  rapidly  spread  with  increase  of  size.  A  week  after 
admission  labour  was  artificially  induced,  and  she  gave  birth  to  a  healthy 
child  ;  but  herself  died  shortly  afterwards  of  collapse.  At  the  necropsy 
both  mammary  glands  were  found  invaded  by  a  softish,  lobulated,  reddish 
growth,  from  which  milky  fluid  exuded  on  section.  Histological  examina- 
tion revealed  epithelial  cylinders  and  alveolar  gland-like  formations,  such 
as  are  found  in  ordinary  breast  cancers,  embedded  in  a  fibrous  stroma 
densely  infiltrated  with  small,  round  cells.  Secondary  nodules  were  dis- 
seminated in  the  thyroid  gland,  pericardium,  liver,  peritoneum  and  kidneys, 
but  not  in  the  axillary  glands.  The  total  duration  of  the  disease  was  only 
six  weeks. 

{b)  In  the  following  case  by  Aitken^  the  progress  was 
even  more  rapid. 

A  cook,  aged  30,  with  both  breasts  enlarged  to  double  their  natural  size, 
of  a  dusky  red  colour,  hot  and  tender  ;  they  adhere  firmly  to  the  adjacent 
parts,  and  feel  firm,  lobulated  and  elastic.  On  puncture  free  hemorrhage 
ensued.  There  was  pyrexia  and  dyspnoea.  She  was  thought  to  be  pregnant. 
The  onset  of  the  disease  dated  only  from  ten  days  previously,  and  she 
attributed  it  to  a  chill.  Eighteen  days  later  there  was  obvious  loss  of 
strength,  with  typhoid  symptoms,  and  she  died  a  week  later,  almost  hemi- 
plegic.  The  total  duration  of  the  disease  was  only  thirty-eight  days.  After 
death  the  right  breast  was  rather  larger  than  the  left.  On  section  each 
presented  a  lobulated  appearance,  and  weighed  six  pounds  fourteen  ounces. 
There  were  cancerous  glands  in  each  axilla,  as  well  as  in  the  liver  and  both 
ovaries.  Microscopical  examination  of  the  diseased  breasts  showed  pro- 
liferating acinous  structures,  as  in  ordinary  cancer. 

Similar  cases  have  been  recorded  by  Klotz,'^  Volkmann,* 
Terrillon,^  Monod*^  and  others. 

(ii.)  Although  I  do  not  regard  the  squirrJie  tegitnientaire  of 
Velpeau  as  a  distinct  variety,  but  merely  as  a  peculiar  form  of 
cutaneous  dissemination  of  ordinary  acinous  cancer,  yet  it  will 
be  convenient  to  describe  it   here.     Acinous  cancers   that  ori- 


'-  Medical  Tij?ies  and  Gazette,  vol.  i.,  1857,  p.  357. 

^  "  Ueber  Mastitis  carcinomatosa  gravidarum  et  lactanlium,"  I.  D.  Halle,  1869. 

■*  Beitr.  z.Chirurgie,  Leipzig,  1875,  S.  310. 

^  Btill.  Gen.  de  I'heraf^.,  13  mai,  189 1,  p.  385. 

«  Gaz.  Med.  de  Paris,  1886,  pp.  i,  17,  37  and  48. 


320  THE    VARIETIES    OF    ACINOUS    CANCER. 

ginate  beneath  the  nipple  and  areola  are  specially  prone  to  be 
followed  by  acute  dissemination  in  the  skin,  owing  to  early  im- 
plication of  the  subareolar  lymphatic  plexus,  and  rapid  diffusion 
of  cancer  cells  through  its  communicating  cutaneous  branches. 
Lesions  thus  induced  assume  the  form  either  of  small  tubercles 
{squirrhe  dissemine,  acute  miliary  carcinosis),  of  irregularly 
shaped  discs  {en  plaques),  or  of  diffuse  infiltrations  {en  cuirasse). 
Velpeau,  who  first  clearly  differentiated  these  conditions, 
thought  that  some  cases  were  from  first  to  last  limited  entirely 
to  the  skin,  but  most  pathologists  are  now  agreed  that  the 
cutaneous  infiltration  is  invariably  secondary  to  primary  disease 
of  the  breast.  Cases  of  this  type  run  a  rapid  course,  and  are 
excceedingly  malignant.  According  to  Estlander,  the  average 
duration  of  life  seldom  exceeds  from  five  to  twelve  months. 
This  estimate  is  no  doubt  true  for  those  cases  in  which  the 
skin  is  implicated  at  an  early  stage  of  the  disease  ;  but  I  have 
seen  instances  in  which  cutaneous  dissemination  did  not 
supervene  until  several  years  after  the  onset  of  the  primary 
disease  in  the  breast. 

Of  170  cases  of  mammary  cancer  consecutively  under  my 
observation,  there  were  only  two  instances  of  squirrhe  dissentinc. 
The  following  is  a  typical  example. 

A  pale,  weak,  emaciated  woman,  aged  32,  the  mother  of  five  children,  with 
a  small,  hard  tumour  in  the  left  breast,  of  one  month's  duration.  The  over- 
lying skin  is  adherent,  and  it  contains  an  immense  number  of  small  cancerous 
nodules,  varymg  in  size  from  a  pea  to  a  pin's  head,  which  are  in  some  places 
confluent.  The  skin  of  the  parts  adjacent  to  the  left  breast  is  similarly 
affected,  as  well  as  that  of  the  left  axilla,  where  the  lymph  glands  are 
enlarged.  In  the  course  of  the  next  few  months  the  opposite  breast  and 
the  whole  of  the  integument  of  the  front  of  the  chest  was  similarly  invaded. 
No  operation  was  done.  She  died  thus  of  asthenia,  with  symptoms  of  intra- 
thoracic dissemination,  seven  and  a-half  months  after  the  disease  was  first 
noticed.  She  was  of  a  very  tubercular  family,  both  her  parents  and  three  of 
her  brothers  and  sisters  having  died  of  phthisis  ;  but  there  was  no  family 
history  of  cancer. 

In  the  diffuse  form  the  onset  is  generally  insidious  and  pain- 
less, like  that  of  ordinary  cancer.  Too  often  nothing  wrong  is 
noticed  until  the  disease  has  made  considerable  progress.     The 


THE    ACUTE    TYPE.  32  I 

first  thing  to  attract  attention  often  is  the  presence  in  the  mam- 
mary skin  of  one  or  more  dusky  red,  erysipelatous-looking, 
hard  plaques.  These  may  be  accompanied  by  a  feehng  of  heat 
and  burning,  together  with  a  vague  sense  of  discomfort,  sleep- 
lessness and  loss  of  appetite.  As  the  disease  progresses,  these 
indurated  areas  increase  and  coalesce,  thus  converting  the  skin 
into  a  hard,  coriaceous  structure  of  dusky  red  colour,  and  fixing 
it  firmly  to  the  subjacent  parts.  This  leather-like  transformation 
often  extends  far  beyond  the  region  of  the  originally  affected 
breast.  It  may  even  involve  the  skin  of  the  whole  trunk,  trans- 
forming it  into  a  constrictive  aiirasse,  as  in  one  of  Velpeau's^ 
cases,  which  he  describes  as  follows  : — 

"Toute  la  poitrine,  depuis  les  flancs  jusqu'au  cou,  depuis  I'ombilic  jusqu' 
au  larynx,  depuis  les  lombes  jusqu'k  I'occiput,  avait  subi  la  transformation 
ligneuse  et  qu'etait  en  outre  criblee  d'ulct;res  squirrheux,  avec  une  foule  de 
bosselures  cancereuses,  jusque  dans  les  aisselles  et  sur  les  epaules.  Cette 
pauvre  femme,  dont  les  deux  bras  dtait  triples  de  volume  et  dur  comme  du 
marbre,  avait  la  respiration  si  petite,  si  courte,  qu'elle  ressemblait  k  une 
personne  qu'on  etrangle,  ou  dont  la  poitrine  est  violemment  prise  dans  un 
etau  ;  ne  pouvant  remuer  ni  les  bras,  ni  la  tete,  eprouvant  des  douleurs 
atroces  a  tout  instant,  elle  offrait,  quand  je  la  vis,  le  spectacle  le  plus 
navrant  qui  se  puisse  imaginer,"  &c. 

Soon  death  ensues,  which  is  generally  due  either  to  acute 
cachexia,  to  extension  of  the  disease  to  the  thorax  causing 
hydrothorax,  &c.,  or  to  constrictive  dyspnoea,  owing  to  me- 
chanical interference  with  the  respiratory  movements. 

Histological  examination  of  the  thickened  skin  shows  that 
the  corium  is  infiltrated  with  cancerous  new  formation,  consist- 
ing of  irregular  aggregations  of  polyhedric  or  variously  shaped 
epithelial  cells,  closely  packed,  without  definite  arrangement, 
in  the  irregularly  shaped  meshes  of  a  fibrous  reticulum.  These 
meshes  appear  to  be  dilated  lymph  spaces.  There  is  seldom 
any  definite  alveolar  formation,  and  sometimes  the  spaces  con- 
tain only  a  single  file  of  cells.  The  epidermis  is  unaffected.  I 
have  seen  two  examples  of  similar  disease  in  the  neck,  which 


'  Traile  des  Maladies  du  Seiii,  Paris,  1S54,  p.  429, 
21 


32  2  THE    VARIETIES    OF    ACINOUS    CANCER. 

probably  originated  in  connection  with  epithelial  remains  of  the 
branchial  clefts.^ 

Of  170  cases  of  mammary  cancer  consecutively  under  my 
observation,  there  were  only  three  instances  of  this  cuirassed 
form  of  the  disease.  According  to  Gross  it  is  met  with  once 
in  every  twenty-two  cases.  The  following  are  two  typical 
examples  : — 

{a)  A  pale,  dark-complexioned  woman,  aged  45,  the  mother  of  five  chil- 
dren. When  I  first  saw  her  the  skin  of  the  whole  of  the  right  pectoral  and 
axillary  regions,  and  part  of  that  of  the  left  pectoral  region,  was  infiltrated 
with  cancer  en  cinrasse,  firmly  adherent  to  the  subjacent  parts.  Several 
hard  cancerous  nodules  could  be  felt  besides  in  the  right  breast.  The  glands 
of  the  right  axilla  were  invaded,  and  the  right  upper  limb  was  oedematous. 
The  disease  began  three  years  previously,  when  she  first  noticed  a  hard 
lump  beneath  the  skin  of  the  right  breast,  just  above  the  nipple.  No  opera- 
tion had  been  performed.  She  died  asthenic  a  month  and  a-half  later,  with 
dissemination  of  the  disease  in  both  lungs,  and  in  the  glands  of  both  axillre. 

{b)  '-"A  childless  married  woman,  aged  52,  six  months  ago  first  noticed  a 
painless  enlargement  of  her  right  breast,  which  increased  rapidly.  At  the 
end  of  this  period  the  breast  was  amputated,  but  recurrence  set  in  before 
the  wound  had  healed.  The  whole  of  the  adjacent  part  of  the  chest  was 
quickly  infiltrated,  together  with  the  axilla  and  shoulder.  The  upper  limb 
became  oedematous  and  useless.  The  skin  of  the  afifected  part  was  bound 
to  the  subjacent  tissues  and  thickened.  It  was  of  reddish  coriaceous 
character,  and  the  papillary  structures  seemed  hypertrophied.  The  infiltra- 
tion soon  involved  the  skin  of  the  scapular  region,  of  the  lateral  and  anterior 
parts  of  the  chest,  and  spread  across  the  niiddle  line  to  the  left  breast, 
which  enlarged  to  more  than  double  its  natural  size  and  became  hard  and 
fixed.  Itching  and  sharp  shooting  pains  were  complained  of.  The  patient's 
general  health  was  soon  affected  ;  her  appetite  failed  and  she  could  not 
sleep  ;  she  rapidly  lost  flesh  and  strength  ;  and  the  breathing  became 
hurried.  On  waking,  after  a  quiet  night,  she  died  suddenly,  eight  months 
after  the  onset  of  the  disease.  At  the  necropsy  there  was  serous  effusion 
into  the  pericardium  and  the  right  pleura  ;  but  710  metastases.  The  other 
organs  were  healthy. 

Ciii.)  I  here  propose  to  call  attention  to  certain  cases  of 
mammary  cancer,  which — although  they  in  no  way  differ 
morphologically  from  ordinary  acinous  cancers — nevertheless 
run  a  very  acute  course.     I  have  met  with  six  such  ca.scs  out  of 


^Medical  Press  and  Circular,  Oct.   29,    18S4.     "Two  Cases  of  Acute   Diffuse 
Slr.ingulating  Cancer  of  the  Neck." 

"  Nunnely,  Trans-  Path-  Soc.  Lond.^  vol,  xiii.,  p.  47. 


THE    CHRONIC    TYPE.  323 

sixty-four  consecutively  fatal  breast  cancers.     The  following  is 
a  typical  example  : — 

A  moderately  nourished,  single  woman,  aged  30,  five  months  ago  first 
noticed  a  hard  lump,  the  size  of  a  bantam's  egg,  in  the  axillary  segment  of 
her  right  breast.  On  examination,  I  found  in  this  situation  a  hard  mass  of 
new  growth,  the  size  of  half  an  orange,  adherent  to  the  chest  wall  and  to  the 
overlying  skin.  The  glands  of  the  right  axilla  were  extensively  infiltrated 
and  matted  together.  Family  history  good.  No  operation.  She  died  of 
asthenia  about  five  and  a-half  months  later.  At  the  7tecropsy  the  body  was 
greatly  emaciated.  A  large  ulcerated  cancerous  growth  occupied  the  right 
breast,  and  the  adjacent  soft  parts  were  infiltrated.  It  was  of  firm,  whitish 
scirrhous  structure.  The  sternum  and  adjacent  pleura  were  infiltrated  with 
similar  growth.     The  liver  contained  numerous  secondary  nodules.'" 

§  II. The  Chronic  Type. 

Mammary  cancers  that  take  more  than  five  years  to  run 
their  entire  course  I  reckon  as  of  the  chronic  variety.  Such 
cases  are  much  commoner  than  is  generally  supposed,  and  what 
is  still  less  appreciated  is,  that  the  great  majority  of  them 
are  morphologically  indistingitishable  from  ordinary  acinous  cancer 
{scirrhiis). 

(i.)  Of  170  consecutive  women  with  mammary  cancer  under 
my  observation,  no  less  than  31  (i8-2  per  cent.)  were  of  the 
chronic  type ;  and  of  these,  all  but  six  were  morphologically  of 
the  ordinary  acinous  kind.  The  duration  of  the  disease  in  these 
25  chronic  acinous  cancers  had  already  lasted  as  follows  : — 

5     to      10   years    ... 
10      ,.      15        ,,         

15  n  20  „  

20  „  25  „  

Over  25        „         

Similarly  of  64  consecutive  fatal  cases,  that  had  run  their 
natural  course,  in  17,  or  26-5  per  cent,  the  disease  had  lasted 
upwards  of  five  years  ;  and  of  these  all  but  3  were  of  the  ordinary 
scirrhous  type.  The  total  duration  of  life  in  these  14  chronic 
scirrhus  cases  was  as  follows  : — 

'"For  abstracts  of  similar  cases  vide  pp.  177  (No.  4),  1S9,  194,  and  218, 


m 

14 

cases. 

,, 

6 

>> 

)! 

2 

)> 

" 

I 
I 

case. 

324  THE    VARIETIES    OF    ACINOUS    CANCER. 

5     to     lo  years     ...  ...         in     8  cases. 

lo      „      15      „         „      5       ,. 

Over  20      „  ...  ...  „      I   case. 

The  3  subjoined  cases,  that  have  come  under  my  own  observa- 
tion, suffice  to  iUustrate  the  chief  features  of  this  form  of  chronic 
cancer. 

Case  i. — A  large,  well  nourished,  healthy  looking,  dark  complexioned 
woman,  aged  55,  the  mother  of  four  children.  In  the  middle  of  her 
left  breast  is  a  hard  nodular  lump,  the  size  of  a  small  orange.  It  is 
adherent  to  the  overlying  skin,  but  movable  on  the  chest  wall.  The 
nipple  is  stunted  and  retracted,  and  the  axillary  glands  are  full.  Twenty- 
eii^ht  years  previously,  shortly  before  the  birth  of  her  first  child,  she  noticed 
a  lump  the  size  of  a  hazel  nut  in  the  middle  of  her  left  breast,  beneath  the 
nipple.  It  remained  nearly  stationary  until  ten  years  ago,  but  ever  since 
that  time  it  has  continued  gradually  to  increase.  Her  father  died  of  cancer 
of  the  lip.  The  breast  was  amputated,  and  the  tumour  proved  to  be  ordinary 
scirrhus.  She  was  convalescent  about  a  month  later,  and  I  know  nothing 
of  her  subsequent  history. 

Case  2. — As  in  the  preceding  instance,  this  patient  was  large,  well 
nourished,  and  of  dark  complexion,  a  cook  by  occupation,  aged  69.  She 
had  recurrent  cancer  of  the  left  pectoral  region,  in  the  shape  of  a  hard, 
knobby  mass,  the  size  of  an  orange,  near  the  axillary  extremity  of  the  scar 
resulting  from  amputation  of  the  breast.  The  growth  adhered  to  the  over- 
lying skin  and  to  the  subjacent  chest  wall.  In  the  left  axilla  was  a  hard 
nodulated  lump  the  size  of  a  hen's  egg,  adherent  to  the  overlying  skin.  The 
disease  began  twenty-three  years  ago,  when  she  first  noticed  a  hard  lump, 
the  size  of  a  pigeon's  egg,  in  the  lower  segment  of  her  left  breast.  In  the 
course  of  four  years  it  attained  the  size  of  a  man's  fist,  and  the  overlying  skin 
having  ulcerated,  the  breast  was  amputated.  Four  years  after  this  a  recur- 
rent growth  in  the  scar,  the  size  of  a  hen's  ^g'g^  was  excised.  For  eight 
years  she  then  remained  free  from  any  return  of  the  disease.  At  the  end  of 
this  time,  about  five  years  ago,  the  present  recurrent  disease  was  first  noticed 
in  the  pectoral  region,  and  subsequently  in  the  axilla.  Her  mother  died  of 
phthisis.  The  patient  married  at  twenty-five,  and  in  the  next  few  years  had 
one  still-born  child  and  one  miscarriage.  No  further  operation  was  done. 
She  died  about  a  year  later  of  asthenia,  the  pectoral  growth  having  previously 
ulcerated.  The  total  duration  of  the  disease  was  nearly  tiucnty-fotir  years. 
At  the  ftecropsy  the  chest  wall  and  axilla  were  found  to  be  extensively  infil- 
trated by  hard,  dense  white,  nodular  cancerous  growths.  There  were  no 
other  secondary  lesions.  Both  lungs  were  emphysematous  and  congested. 
There  were  old  fibrous  adhesions  over  the  upper  part  of  the  left  lung.  The 
heart  presented  an  excessive  amount  of  subpericardial  fat.  The  liver  was 
congested.  The  kidneys  were  small  and  granular,  the  cortex  of  each  much 
wasted,  containing  a  few  small  cysts.  The  uterus  was  small,  and  at  its 
fundus  were  two  calcified  pendulous  fibroids.     The  brain  was  normal. 


THE    CHRONIC    TYPE. 


O^D 


Case  3. — A  large,  fleshy,  dark-complexioned,  sallow  woman,  aged  57, 
with  an  ulcerated  mass  of  hard  cancerous  growth,  about  the  size  of  a  man's 
hand,  occupying  the  left  pectoral  region,  in  the  situation  of  the  mamma. 
The  surrounding  skin  and  other  structures  are  infiltrated.  The  mass  is 
firmly  adherent  to  the  subjacent  chest  wall.  The  discharge  from  the  ulcer 
is  abundant  and  foetid.  The  left  axillary  glands  are  enlarged.  The  disease 
began  sixteen  years  ago,  when  she  first  noticed  a  lump,  the  size  of  a  hazel 
nut,  at  the  lower  peripheral  part  of  the  left  breast  ;  this  slowly  increased  for 
about  twelve  years,  and  then  began  to  ulcerate.  In  consequence  the  breast 
was  amputated  about  a  year  later,  and  the  axillary  glands  were  removed. 
Ten  months  later  a  recurrent  growth  in  the  pectoral  region  was  excised  ; 
shortly  afterwards  the  present  recurrence  began  there.  She  was  married 
at  17,  and  is  the  mother  of  two  children.  Both  her  parents  died  young  of 
phthisis.  No  further  operation.  She  was  last  seen  about  seven  months 
later,  when  her  strength  was  failing  and  cachectic  symptoms  were  well 
marked.     The  disease  then  had  already  lasted  nearly  seventeen  years. 

In  point  of  chronicity  it  would  be  difficult  to  surpass  such 
cases,  even  among  the  atrophic  and  colloid  varieties  of  the 
disease,  v/hich  are  generally  supposed  to  have  a  monopoly  in 
this  respect. ^"^ 

(ii.)  The  form  of  cancer  I  now  have  to  describe  is  rare, 
for  of  170  consecutive  mammary  cancers,  I  met  with  only  six 
instances  of  it,  or  3'5  per  cent.  According  to  Gross,  atrophic 
varieties  constitute  about  7'9  per  cent,  of  all  breast  cancers. 

The  characteristic  feature  of  this  type  is  the  continuous, 
gradual  shrinking  of  the  new  formation,  and  the  consequent 
irregular  contraction  of  the  breast,  which  is  often  thereby  dimin- 
ished rather  than  increased  in  size.  The  deformity  produced 
is  apt  to  resemble  that  met  with  in  "  chronic  cirrhosing  mastitis." 
These  atrophic,  cicatrising  or  cirrhosing  cancers  usually  begin 
with  obscure  hardness,  which  progresses  slowly,  forming  at 
length  ill-defined,  flattened  or  irregular  nodulated  thickening, 
with  numerous  "roots"  stretching  far  into  the  adjacent  parts. 
Such  growths  consist  of  very  dense,  whitish,  dry,  fibroid  sub- 
stance, and  on  account  of  their  extreme  hardness,  they  have 
not  inappropriately  been  designated  "  stone  cancers." 

Histologically  the  fibrous  stroma  preponderates,  while  epi- 
thelial elements  are  very  scanty,  or  altogether  wanting  (fig.  43). 

"  For  other  instances  of  extreme  chronicity,  vide  chap,  ix.,  pp.  219  and  220. 


326  THE    VARIETIES    OF    ACINOUS    CANCER. 

This  stroma  consists  of  irregularly  disposed  bundles  of  fibrous 
tissue,  rich  in  elastic  fibres,  but  poor  in  cellular  elements.  It 
contains  variously  shaped  small  spaces — atrophied  alveoli — in 
which  are  a  (e\v  degenerate  epithelial  cells,  or  merely  cellular 
debris  and  fatty  granules.  The  constituent  cells  of  cancers  of 
this  kind  are  very  short  lived,  for  no  sooner  have  they  formed 
than  they  thus  degenerate;  only  at  their  extreme  periphery 
are  proliferous  epithelial  cells  to  be  found.  A  notable  feature 
of  atrophic  cancer  is  the  marked  deformity  of  the  breast, 
caused  by  the  shrinkage   of  the  neoplasm  ;    at  first  only   the 


FlU.  43.— liistoluj^ical  Section  of  atrophic  Mammary  Cancer  {Billroth). 

nipple  and  skin  are  retracted,  but  finally  the  latter  is  thrown 
into  obvious  plications.  The  subcutaneous  veins  arc  seldom 
seen  distended,  as  in  ordinary  cancers.  Usually  the  disease 
runs  an  extremely  chronic  course,  most  cases  lasting  for  from 
ten  to  fifteen  years  or  more  ;  but  spontaneous  cures  are,  never- 
theless, unknown.  Here  I  may  as  well  mention,  that  I  have 
met  with  several  examples  of  atrophic  cancer,  that  have  run 
their  entire  course  in  less  than  a  year.'^ 

The  general  health  of  women  with  atrophic  cancer  usually 
remains  unimpaired  for  a  long  time ;  but  at  length  cachectic 
symptoms  supervene.     Shallow  indolent  ulcerations  often  result, 

'-  I  have  reported  two  typical  cases  of  this  kind  in  chap,  ix.,  p.  203. 


THE  CHRONIC  TvrE.  327 

which  occasionally  partially  cicatrise.  Old  women  are  said 
to  be  particularly  liable  to  atrophic  cancer  ;  but  this  is  only 
partially  true.  Most  cases  supervene  at  a  more  advanced  period 
of  life  than  ordinary  scirrhus  ;  but,  as  Gross  has  pointed  out, 
quite  55  per  cent,  originate  before  the  age  of  50. 

Atrophic  cancers  are  specially  prone  to  invade  extensively 
the  adjacent  tissues  by  direct  extension,  and  in  a  less  degree 
by  local  dissemination.  Lymph  glandular  and  general  dis- 
semination, although  often  long  delayed,  are  seldom  absent ; 
and  recurrence  after  operation  is  of  frequent  occurrence. 
The  secondary  growths  reproduce  the  atrophic  characteristics 
of  the  primary  one. 

Subjoined  are  abstracts  of  some  typical  cases,  that  have 
come  under  my  observation.^-^ 

(a)  A  pale,  sallow,  and  thin  woman,  aged  76,  with  both  mammae  small 
and  wasted.  The  greater  part  of  the  left  breast  is  occupied  by  an  irregular 
ulcer  rather  larger  than  the  palm  of  the  hand.  Its  base  is  fixed  to  the 
subjacent  chest  wall.  The  nipple  and  areola  are  quite  destroyed.  Its  edges 
are  raised  and  hard.  The  left  axillary  glands  and  those  above  the  clavicle 
on  this  side  are  enlarged.  At  the  upper  part  of  the  right  breast  there  is  a 
smaller  cancerous  ulcer.  Twenty  years  previously  she  first  noticed  a  small 
nodule  in  the  left  breast  near  the  nipple.  It  has  since  slowly  attained  its 
present  condition.  Ten  months  ago  a  similar  nodule  was  first  noticed  in 
the  upper  part  of  her  right  breast.  No  operation  has  ever  been  done.  Her 
maternal  grandmother  died  of  cancer  of  the  breast,  and  her  father  of 
phthisis. 

(d)  A  well  nourished  but  sallow  woman  of  dark  complexion,  aged  52, 
with  a  linear  scar  across  the  right  mammary  region,  at  the  middle  of  which 
is  a  hard  recurrent  nodule  the  size  of  an  almond.  A  single  enlarged  gland 
in  the  right  axilla.  Five  days  ago,  when  out  walking,  she  suddenly  felt  a 
pain  in  her  right  thigh,  which  caused  her  to  fall,  when  it  was  found  that  she 
had  fractured  her  femur  at  the  junction  of  its  upper  and  middle  thirds. 
The  patient  said  she  first  noticed  a  hard  lump,  the  size  of  a  pea,  at  the 
upper  part  of  the  periphei^y  of  her  right  breast,  ten  years  ago.  After  it  had 
slowly  increased  for  six  years,  the  breast  was  amputated.  The  present 
recurrent  nodule  was  only  recently  noticed.  No  further  operation  was 
done.  She  died  of  asthenia  nineteen  months  later.  At  the  necropsy^  both 
pectoral  regions  were  found  infiltrated  with  hard  cancerous  growths,  which 
had  invaded  the  muscles  and  ribs,  and  had  spread  by  direct  extension  to 
the  anterior  mediastinum  and  to  both  pleurae.  The  glands  in  both  axillje 
were  infiltrated.     A  cancerous  nodule  m  the  pancreas    had  invaded  and 

'^  For  other  cases  vide  ch.  ix.,  pp.  229  and  230. 


328  THE    VARIETIES    OE    ACINOUS    CANCER. 

blocked  the  common  bile  duct,  at  its  entrance  into  the  duodenum.  The 
gall  bladder  was  dilated  and  contained  several  calculi.  A  fistulous  com- 
munication had  established  itself  between  the  gall  bladder  and  duodenum. 
The  liver  was  atrophic  and  of  brownish  tint.  The  heart  and  lungs  were 
small.  Both  kidneys  were  small,  and  the  pelvis  of  each  contained  numerous 
miliary  calculi.  The  whole  of  the  right  femur  was  infiltrated  with  cancerous 
growth  ;  and  it  was  fractured  in  several  places.  The  head  of  the  right 
ti1)ia  was  similarly  invaded.  The  left  femur  was  fractured  just  below  the 
small  trochanter  ;  and  here  there  was  a  mass  of  cancerous  growth  the  size 
of  an  orange.  The  whole  of  the  left  humerus,  except  the  articular  ex- 
tremities, was  converted  into  a  mass  of  cancerous  growth.  The  growth 
in  the  left  femur  was  of  a  whitish  colour  and  india-rubber-like  consistency  ; 
and  on  histological  examination  proved  to  be  typical  acinous  (alveolar) 
cancer. 

{c)  A  rather  pale,  emaciated  and  sallow  woman,  aged  46,  with  a  hard 
flattened  mass  near  the  middle  of  her  right  breast,  over  which  the  skin  is 
plicated  and  adherent,  and  the  nipple  deeply  retracted.  The  axillary  glands 
are  enlarged  and  hard.  The  disease  began  as  a  small  nodule  at  the  lower 
and  inner  part  of  the  breast,  five  years  ago.     No  operation  had  been  done. 

{d)  '^  A  lady,  who  died  aged  75,  twenty-four  years  previously,  after  having 
borne  a  numerous  healthy  family,  first  noticed  a  small  hard  tender  lump 
in  her  left  breast,  with  retraction  of  the  nipple.  She  would  not  submit  to 
operation.  In  the  course  of  several  years  the  breast  got  much  harder  and 
smaller,  and  the  skin  became  puckered  ;  until  at  length  the  gland  seemed 
to  have  almost  completely  disappeared.  During  the  last  eight  years  of  her 
life  the  disease  seenied  stationary  ;  and  it  caused  her  hardly  any  pain  or 
inconvenience.  When  first  seen  two  years  before  her  death,  the  whole 
breast  appeared  to  have  shrivelled  up  and  wasted  away.  The  prominence  of 
the  bosom  had  quite  disappeared;  in  its  place  was  a  flat  surface,  contrasting 
markedly  with  the  opposite  side,  where  there  was  a  full  bust.  The  nipple 
was  deeply  retracted  and  sunk  in  a  fossa,  whence  radiated  grooves  and 
fissures.  Beneath  it  there  was  a  small  hard  infiltrated  area,  with  a  few 
hard  tubercles  adjacent.  The  patient  came  under  treatment  for  senile 
cataract  of  both  eyes,  which  had  made  her  quite  blind.  Notwithstanding 
the  cancerous  disease  she  was  operated  on  successfully  and  made  an 
excellent  recovery.     There  was  r\o  post-vwrtcin  examination. 

(ill.)  Colloid  cancer  of  the  breast  is  certainly  very  rare,  since 
of  170  consecutive  cancers  of  this  part  I  have  not  met  with  a 
single  instance  of  it.  Gross  estimates  that  i'34  per  cent,  of  all 
breast  cancers  are  of  this  variety ;  and  Brindejonc'^  reports 
eii^ht    exainples  of   it    in   326  cases. 

The  disease  owes  its  peculiar  features  to  the  proneness 
of  its  constituent  cells  to  undergo  colloid  metamorphosis. 


"  E.  Hart,  Trans.  Path.  Sor.,  vol.  xiii.,  p.  225. 

'•''  "  Etude   sur   qucliiucs  carcinoiiics  cuIUiides  de  la  Mainelle,"    T/iese  tie  Faris^ 
No.  373,  1891. 


THE    CHRONIC    TYl'E. 


329 


Sections  of  such  growths  reveal  small,  translucent  masses  of 
glutinous  fluid,  embedded  in  the  fibrous  stroma,  in  place  of  the 
usual  opaque  cellular  aggregations  (fig.  44).  It  comparatively 
seldom  happens,  however,  that  the  whole  neoplasm  is  thus 
affected,  for  some  parts  nearly  always  retain  their  ordinary 
scirrhous  character. 

The  process  begins  with  the  formation  within  the  cells  of 
clear  colloid  globules.  As  these  increase  the  cells  perish  ;  the 
freed    globules   then  coalesce  and   so    form  the   larger   colloid 


j/--^4:j^^ 


Fig.  44. — Histological  Section  of  Colloid  Cancer  of  the  Breast  (Cazin). 

masses.  Thus  all  the  cancer  cells  of  a  wide  area  may  perish  ; 
so  that  the  stroma  is  the  only  formed  constituent  left.  In  other 
parts  of  the  same  growth  regions  may  be  found  in  which  the 
cells  are  merely  fringed  with  colloid  change ;  and  in  yet  other 
localities  no  colloid  change  may  be  noticeable.  As  the  disease 
progresses  the  fibrous  stroma  often  becomes  edematous,  and 
much  of  it  may  eventually  disappear,  leading  sometimes  to 
cyst  formation.      Histological  sections  show  large,  thin-walled 


330  THE    VARIETIES    OF    ACINOUS    CANCER. 

alveoli,  distended  with  colloid  fluid  containing  granular  debris, 
in  which  only  a  i&sN  degenerated  cells,  or  perhaps  none  at  all, 
can  be  made  out  (fig.  44).  Owing  to  these  changes  in  the  cells 
their  growth  is  retarded  and  the  malignancy  of  the  disease  is 
thereby  diminished  ;  hence  colloid  cancers  run  a  very  chronic 
course,  the  average  duration  of  life  being  about  twelve  years ; 
and  they  are  more  tardily,  and  less  frequently,  followed  by  local, 
glandular  and  general  dissemination,  than  any  other  form  of 
mammary  cancer.  Moreover,  in  this  variety  of  the  disease 
cachectic  symptoms  seldom  supervene.  When  secondary 
growths  do  arise,  in  their  main  features  they  resemble  the 
primary  ones. 

Colloid  cancer  usually  begins  as  a  small,  lumpy  swelling  in 
the  breast,  which  increases  very  slowly.  The  resulting  tumour 
seldom  exceeds  the  size  of  a  hen's  ^%%,  and  it  may  take  from 
ten  to  fifteen  years  to  attain  this  size.  It  generally  feels  firm 
and  elastic,  with  projecting  bosses.  As  these  growths  do  not 
shrink,  the  nipple  and  overlying  skin  are  much  less  frequently 
retracted  than  in  ordinary  scirrhus.  Ulceration  occasionally 
ensues  at  an  advanced  stage  of  the  disease.  Recurrences  are 
less  frequent  than  after  the  removal  of  any  other  form  of 
mammary  cancer.  The  average  age  at  onset  is  47  years  ;  and 
in  about  half  the  cases  the  disease  begins  after  50. 

The  following  is  an  illustrative  case.^** 

A  healthy,  married,  childless  woman,  aged  65,  with  a  lobiilated  livid 
tumour — of  seven  years'  growth — the  size  of  a  man's  fist,  occupying  her 
right  breast.  The  lobulations  feel  soft  and  fluctuating  ;  in  one  of  them  is 
an  opening,  whence  thick,  glairy  fluid  escapes.  On  section  after  removal 
the  lobular  structure  was  well  marked.  Each  lobulation  was  composed  of 
reddish  jelly-like  material  with  caseating  areas  in  it.  Histological  examina- 
tion revealed  delicate  fibrous  alveolar  stroma,  containing  glutinous  fluid  in 
which  were  large  granulation-like  cells.  There  was  no  recurrence  of  the 
disease  in  this  breast  ;  but  seven  years  afterwards  she  developed  cancer 
(colloid?)  in  the  opposite  breast.  Six  years  later  this  had  but  slightly 
increased  ;  and  she  was  still  in  good  health. 


"'  Bryant,  Op.  cit.,  p.  201.  For  other  cases  vide— Trans.  Path.  Soc,  xxx. 
(Godlee),  p.  416;  xxix.  (Watson),  ]i.  218;  xxvii.  (Bullin),  p.  233.  Arch.  f.  kliii. 
Chir.  (Doutrelepont),  Bd.  xii.,  S.  551.  Thhe  de  Paris  (Brindejonc),  No.  373, 
1891,  &c. 


THE    MELANOTIC    TYPE.  33 1 

(iv.)  Many  cases  of  so-called  colloid  cancer  of  the  breast  are 
really  examples  of  carcinoma  uiyxoniatodcs^  the  variety  now  to 
be  described.  The  gelatinous  transformation  is  here  due  to 
myxomatous  metaplasia  of  the  fibrous  tissue  of  the  stroma ; 
and  in  extreme  cases  to  its  cellular  elements  as  well.  Very 
exceptionally,  it  may  even  happen  that  the  cancer  cells  them- 
selves thus  degenerate.  In  this  connection  it  should  be  borne 
in  mind  that  a  layer  of  mucoid  connective  tissue  is  normally 
present  immediately  around  the  ducts  and  acini.  Eve^''  has 
recorded  the  two  following  typical  examples  : — 

(a)  A  lady,  aged  about  80,  with  a  rather  soft,  bossy,  circumscribed 
tumour,  at  the  lower  part  of  her  breast,  of  three  years'  growth.  Her  general 
health  was  unimpaired  ;  and  there  was  no  obvious  enlargement  of  the 
adjacent  lymph  glands.  On  examination  after  removal,  a  pale,  soft  growth 
was  revealed,  which  contained  much  thick  gelatinous  material.  Histologi- 
cally it  was  composed  of  narrow  columns  of  spheroidal  epithelial  cells,  sup- 
ported by  myxomatous  connective  tissue.  The  latter  contained  numerous 
nucleated  round  and  spindle  cells,  as  well  as  some  curious  yellow, 
botryoidal  masses — so-called  colloid  bodies — which  appeared  to  have 
originated  from  mucoid  degeneration  of  small  groups  of  connective  tissue 
cells.  The  cancer  cells  themselves  were  exceedingly  well  preserved,  and 
appeared  to  be  unaffected  by  these  degenerative  changes. 

{b)  In  this  case  the  breast  was  removed  from  a  woman,  aged  35,  for  a 
so-called  colloid  cancer  of  four  years'  growth.  Its  section  showed  mucoid 
material  embedded  in  a  wide  meshed  connective  tissue  reticulum.  Micro- 
scopical examination  revealed  a  granular  mucoid  stroma,  enclosing  rounded 
columns  of  closely  packed,  but  ill-defined  epithelial  cells. 

A  subvariety  of  this  form  arises — to  which  the  term  cylin- 
droma has  been  applied — when  the  mucoid  stroma  grows  into 
the  epithelial  masses,  and  becomes  more  or  less  enclosed  in 
them,  of  which  a  few  instances  have  been  recorded. 

S     III. The  Melanotic  Type. 

Any  form  of  melanotic  neoplasia  of  the  breast  is  of  extreme 
rarity.  My  table  of  2,397  consecutive  primary  neoplasms 
of  the  female  breast  does  not  contain  a  single  instance.  It 
appears,  however,    to  be   rather    less    exceptional    in  the  male 


'"   Trans.  Path.  Soc.  Lone/.,  vol.  xxxvii.,  1886,  p.  493. 


;^2,^  THE    VARIETIES    OF    ACINOUS    CANCER. 

breast,  for  of  lOO  primary  cancers  of  this  part  collected  by  me/^ 
three  were  of  the  melanotic  variety.  The  greatest  diversity  of 
opinion  exists  among  pathologists,  as  to  the  classification  of 
melanotic  neoplasms.  Billroth  and  others  maintain  that  they  are 
always  sarcomatous  ;  but  this  exclusive  view  as  to  their  origin 
cannot  be  any  longer  maintained,  for  many  well-authenticated 
cases  of  pigmented  epithelial  cancer  have  lately  been  recorded. 
Unna^^  now  holds  that  melanomata  are  invariably  carcino- 
matous. Under  these  circumstances  it  seems  desirable  to  bring 
together  in  this  section  the  chief  cases  of  mammary  melanoma, 
hitherto  recorded,  whether  of  sarcomatous  or  carcinomatous 
nature. 


Fig.  45. — Histological  Section  of  Melanotic  Cancer  of  the  Breast. 
( Coniil  and  Ranvier. ) 
(l)  Glandular  cells  infiltrated  with  Pigment.       (2)  Stroma. 

The  two  subjoined  examples  of  melanoma  of  the  female 
inmniiiary  gland  itself,  are  the  only  cases  of  the  kind  known 
to  mc. 

(i)  -"  A  thin,  pale  woman,  aged  68,  the   mother  of  ten  children,  first 
noticed  a  lump  in  the  outer  and  lower  part  of  her  right  breast  three  years 


'»  Ch.  xvi. 

'"  Berlin  /din.  IVoch.,  No.  I,  1894. 

'^^  Billroth,  Th.,  Deutsche  C/iir.,  Lief,  xli.,  S.  56. 


THE    MELANOTIC    TYPE.  333 

ago.  When  she  came  under  treatment  the  breast  was  lars^er  than  a  child's 
head,  owing  to  the  presence  of  a  hard,  nodular  tumour,  to  which  the  over- 
lying skin  was  adherent.  The  whole  mass  was  movable  on  the  chest  wall  ; 
and  the  axillary  glands  were  enlarged.  The  patient  also  presented  two 
small  congenital  cutaneous  moles  ;  one  beneath  the  right  eye,  and  the 
other  in  the  region  of  the  supra-spinous  fossa.  The  diseased  part  was 
freely  amputated  and  the  axilla  cleared.  On  examination  after  removal, 
it  proved  to  be  a  circumscribed  melanotic  growth.  Its  histological  diagnosis 
appears  to  have  much  exercised  Billroth  ;  for  while  in  his  "  Clinical 
Surgery"  he  describes  it  as  on  the  whole  of  carcinomatous  nature,  in  his 
essay  in  the  DeiitscJie  Chirurgie^  he  classes  it  as  an  alveolar  sarcoma,  and 
then  speaks  of  it  as  a  "combination  of  sarcoma  with  carcinoma."  It  will 
suffice  for  us  to  know  that  a  well  marked  fibrous  alveolar  stroma  was 
present,  the  meshes  of  which  were  filled  with  dense  masses  of  large,  ovoid, 
nucleated  quasi-epithelial  cells,  and  the  pigment  was  mostly  in  the  stroma. 
Before  the  wound  had  healed,  a  fresh  melanotic  gi'owth  formed  in  the  skin 
of  the  back  ;  and  she  died  about  a  year  later  of  marasmus,  but  without 
recurrence  in  the  chest  or  axilla.  I  must  refer  those  who  desire  further 
details  of  this  interesting  case,  to  the  original  article  in  the  Deutsclie 
Chirurgie,  where  its  microscopical  and  macroscopical  features  are  fully 
detailed  and  figured. 

(2)  In  an  instance  mentioned  by  Cornil  and  Ranvier-'  the  gland  pre- 
sented black  spots,  visible  to  the  naked  eye,  and  the  melanotic  substance 
was  contained,  not  in  the  connective  tissue,  but  in  the  epithelial  cells  of  the 
glandular  acini  (fig.  45).  Here  the  pigment  had  evidently  been  secreted  by 
the  cells  themselves.  Such  cases  soon  disseminate  widely  and  cause  death. 
This  being  so,  I  cannot  agree  with  Cornil  and  Ranvier  that  there  is  no  real 
neoplastic  action.  It  seems  to  me  that  it  would  be  just  as  unreasonable  to 
deny  the  existence  of  neoplasia  in  atrophic  and  colloid  cancers,  as  in  these 
melanotic  ones. 

The  three  following  instances  of  similar  disease  in  the  male 
breast  have  also  been  recorded  : — 

(i)  An  Italian,  aged  53,  seen  by  Lawrence,--  with  a  large,  hard,  fungating 
tumour  of  the  right  breast  of  one  year's  duration.  The  skin  and  other  ad- 
jacent soft  parts  extensively  invaded  by  hard  cancerous  nodules.  The  right 
clavicular,  and  the  axillary  glands  of  both  sides,  also  infiltrated.  CEdema  of 
the  right  upper  limb,  and  great  dyspncea.  Palliative  treatment  ;  followed 
by  death  from  asthenia  three  months  later.  At  the  nca'upsy  the  whole  of 
the  soft  parts  of  the  front  of  the  right  side  of  the  chest  infiltrated  by  very 
hard  quasi-fibrous  growth  of  bright  yellowish  green  colour.  The  thoracic 
muscles,  anterior  mediastinal  glands,  right  pleura  and  diaphragm  were 
invaded  by  growths  of  similar  nature,  evidently  by  direct  extension.  There 
was  right   hydrothorax,    with  collapse   of  the   lung.      There   were   metas- 

-'  Manual d'Etist.  Path.,  t.  i.,  331. 
-'-  Med.  Chi?-,  Trans.,  vol.  iii. ,  \>.  "jz. 


334  THE    VARIETIES    OF    ACINOUS    CANCER. 

tatic  nodules  of  bright  coloured,  hard  growth,  like  the  primary  disease,  in 
the  pancreas,  both  kidneys  and  the  base  of  the  bladder.  This  is  evidently  a 
case  of  chloroma?'^ 

(2)  Langenbeck^^  mentions  having  met  with  an  instance  of  recurrent 
melanotic  alveolar  cancer  of  the  male  mamma. 

(3)  -••  The  only  details  I  have  been  able  to  obtain  of  this  case  are  as 
follows  : — The  patient  had  ulcerated  scirrhous  cancer  of  the  breast  of 
two  years'  duration.  The  disease  followed  a  blow.  The  axillary  glands 
were  infiltrated.  On  histological  examination  of  the  growth  after  removal, 
it  proved  to  be  fibrous  alveolar  cancer,  both  the  cells  and  stroma  being 
pigmented. 

The  Hunterian  Museinn  contains  a  specimen  of  melanoma 
of  the  cow's  udder  (No.  469  of  the  Pathological  Series).  It  is 
thus  described  in  the  catalogue  :  "  A-  portion  of  the  udder  of 
an  almost  white  cow.  It  contains  a  tumour  three  inches  long 
and  uniformly  black.  The  skin  of  the  udder  is  marbled  by- 
numerous  pigmented  blotches." 

As  examples  of  melanoma  of  the  mammary  integument  I 
can  cite  the  following  cases  : — 

(i)  Nunn-^  mentions,  without  giving  histological  details,  the  case  of  a 
woman,  aged  73,  with  a  group  of  melanotic  warts  of  the  skin  of  her  right 
bi-east  towards  its  lower  border.  The  axillary  glands  were  enlarged  from 
malignant  infiltration,  and  the  upper  limb  was  oedematous.  She  had  also 
some  hard,  rounded  warts  on  either  side  of  her  forehead.  About  five  months 
later  she  died  of  hemiplegia. 

(2)  Wacker'-'  has  reported  an  example  of  multiple  melanotic  neoplasms 
of  both  breasts,  with  dissemination  in  the  left  axillary  glands,  spleen,  brain 
and  mesenteric  glands.  He  thought  the  disease  originated  in  the  mammary 
integument.     It  is  described  as  "  alveolar  sarcoma." 

(3)  Velpeau-®  has  seen  two  instances  of  melanoma  of  the  mammary 
integument,  one  of  the  areola,  the  other  of  the  breast.  In  both  of  these 
cases  there  were  numerous  melanotic  groWths  elsewhere,  and  it  is  doubtful 
whether  in  either  of  them  the  disease  originated  in  the  mamma. 


-'  For  an  account  of  this  rare  disease  the  reader  is  referred  to  Lang's  *'  Mono- 
graphic du  Chloroma,"  Arch.  Ghi.  de  MM.,  dec,  1893;  also  Jan.,  fev.  and  mars, 
1894.  Among  the  instances  there  cited  the  above  case  is  not  included  ;  nor  is 
any  example  given  of  this  disease  in  the  breast. 

'-*  Med.  Centralzeitiinq,  Hd.  xviii.,  3,  cited  by  Schuchardt. 

■■'  Marcano's  case,  cited  in  Poirier's  "  Tumcurs  du  Sein  chez  1' Homme,"  Paris, 
1883,  p.  51. 

^  "  Cancer  of  the  Breast,"  1882,  p.  105,  No.  48. 

-"  Iiiaui^.  Dissert.,  Rostock,  1884. 

-'  "  Traite  dcs  Maladies  du  Scin,"  p.  456. 


THE    MELANOTIC    TYPE.  335 

(4)  In  the  museums  of  Guy's  and  St,  Bartholomew's  hospitals^''  are  speci- 
mens showing  similar  secondary  melanotic  growths  in  the  breasts. 

(5)  I  have  seen  a  reference  to  a  case  of  primary  melanotic  sarcoma  in 
the  breast  of  an  infant,  by  Vieregge,'"'  but,  as  I  have  been  unable  to  consult 
the  original  report,  I  cannot  give  details. 

Bryant"^^  reports  the  two   following  instances  of  secondary 
melanotic  sarcoma  of  the  breast  : — 

(i)  A  married  woman,  the  mother  of  one  child,  came  under  observation 
with  her  right  breast  covered  and  filled  with  melanotic  lumps  the  size  of 
nuts.  There  were  also  similar  growths  on  the  skin  over  the  sternum, 
abdomen  and  back.  The  axillary  glands  were  much  enlarged.  Ten  months 
previously  a  black  tumour,  the  size  of  a  walnut,  of  a  year's  duration,  had 
been  removed  from  her  left  forearm,  where  it  originated  from  a  mole. 

(2)  A  sterile  married  woman,  aged  55,  four  months  before  she  came 
under  treatment,  had  a  melanotic  tumour — the  size  of  a  duck's  egg — removed 
from  the  skin  over  the  sternum,  where  it  had  originated  from  a  mole.  On 
examination  many  melanotic  growths  were  found  disseminated  over  the 
sternum,  both  breasts  and  the  abdomen.  The  glands  in  both  axilla  were 
enlarged. 


'"'  Vide  the  respective  Pathological  Catalogues. 

^'^  North  Western  Lancet,  St.  Paul,  U.S.A.,  1891,  xi.,  p.  28. 

■^'  "  Diseases  of  the  Breast,"  p.   231. 


CHAPTER     XII. 
The  Clinical  Features  of  Mammary  Cancer. 


S    I. Symptomatology. 

In  the  three  preceding  chapters  several  of  the  cHnical 
features  of  breast  cancer  have  been  described  ;  but  besides  these 
there  are  some  others  that  must  now  be  briefly  noticed. 

Pain. — It  is  a  popular  belief,  in  which  many  practitioners 
share,  that  pain  is  one  of  the  cardinal  symptoms  of  mammary 
cancer.  To  hear  some  people  talk,  one  would  think  that  the 
absence  of  pain  precludes  the  possibility  of  cancer.  Such  ideas 
are  most  erroneous.  There  is,  as  a  rule,  no  pain  in  the  early 
stages  of  cancer  of  the  breast.  It  is  not  until  the  disease  has 
existed  for  a  considerable  time  that  pain  supervenes,  and 
many  cases  run  their  entire  course  without  causing  much  suffer- 
ing. Hence  cancerous  growths  in  the  breast  generally  escape 
notice  until  they  have  attained  a  certain  size ;  and  it  is  often 
only  by  some  trivial  accidental  occurrence  that  the  patient's 
attention  is  first  directed  to  the  disease. 

On  the  other  hand,  benign  tumours,  and  especially  chronic 
inflammatory  swellings,  are  often  attended  with  a  considerable 
amount  of  variable  pain  and  tenderness,;  and  in  the  absence  of 
any  appreciable  lesion  whatever,  pain  may  be  experienced. 

Nothing,  therefore,  can  be  more  fallacious  than  to  attempt 
to  estimate  the  gravity  of  mammary  tumours  by  the  amount 
of  pain  present. 

Generally  speaking,  cancers  do  not  cause  severe  pain  until 


SYMPTOMATOLOGY.  2)37 

the  near  approach  of  ulceration.  Then  the  pain  is  usually 
described  as  of  a  dull  aching,  burning,  stabbing  or  lancinating 
character,  and  it  often  manifests  intermittent  or  quasi-neuralgic 
features. 

The  formation  of  secondary  growths  in  the  axilla  may  cause 
pain,  owing  to  pressure  on  the  nerves.  Pain  thus  induced  is 
generally  referred,  at  first,  to  the  inner  side  of  the  arm  near  the 
elbow. 


Fig.  46. — Cancer  of  the  Breast,  showing  Retraction  of  the  Nipple  and  Puckering 
of  the  Skin  {Bryant). 


Retraction  of  the  Nipple. — When  associated  with  other  signs 
of  cancer,  retraction  of  the  nipple  is  a  valuable  diagnostic  aid, 
but  of  itself  it  has  no  special  significance.  There  is  nothing 
about  it  pathognomonic  of  cancer.  Hence  care  should  be  taken 
to  avoid  jumping  at  the  conclusion,  that  a  neoplasm  is  neces- 
sarily cancerous,  because  it  is  associated  with  a  retracted  nipple. 
Of  207  cancer  cases.  Gross  noticed  retraction  of  the  nipple  in 
108,  or  in  52  per  cent.  It  is  more  frequently  seen  in  association 
with  central,  than  with  peripheral,  neoplasms.  Its  proximate 
cause  in  these  cases  no  doubt  is  shrinkage  of  the  older  parts  of 
22 


338  CLINICAL    FEATURES    OF    MAMMARY    CANCER. 

the  growth,  and  consequent  pulling  on  the  lacteal  ducts.  Hence 
in  cancer  the  nipple  is  generally  not  only  retracted,  but  it  is  also 
drawn  out  of  its  proper  position  in  the  direction  of  the  neoplasm. 
The  whole  gland  is  sometimes  displaced  in  this  way. 

Congenital  imperfection  of  the  nipple  is  often  found  in  asso- 
ciation with  neoplasms.  Of  137  consecutive  cases  of  cancer  of 
the  female  breast,  I  found  congenital  malformation  of  the  nipple 
in  19,  or  in  13*8  per  cent.;  and  of  42  cases  of  fibro-adenoma, 
there  was  similar  mammillary  imperfection  in  10,  or  in  23*8  per 
cent.  Gross'  estimate  of  5 '2  per  cent.,  as  the  proportion  of 
cases  in  which  retraction  of  the  nipple  is  associated  with  non- 
cancerous neoplasms,  appears  to  me  much  below  the  mark. 
Although  these  growths  seldom  cause  retraction  of  the  nipple, 
they  are  not  unfrequently  found  in  association  with  it. 

In  addition  to  the  foregoing,  it  must  be  remembered  that 
retraction  of  the  nipple  may  also  result  from  injury  or  disease 
during  infancy  or  childhood,  and  during  adult  life  it  often  super- 
venes as  an  acquired  condition,  in  the  absence  of  any  tumour, 
owing  to  over-action  of  the  longitudinal  organic  muscle  fibres. 
Finally,  certain  chronic  inflammatory  conditions  of  the  breast . 
— that  in  other  respects  also  often  closely  simulate  cancer — not 
unfrequently  cause  retraction  of  the  nipple,  e.g.,  chronic  mastitis, 
tubercle  and  cold  abscess. 

Dimpling  of  tJie  Skin. — Dimpling  of  the  skin  over  cancerous 
growths  is  one  of  the  earliest  phenomena  of  cancer;  and  it  is 
seldom  or  never  wanting  at  some  stage  or  other.  It  occurs 
long  before  any  adhesion  has  taken  place  between  the  skin  and 
the  growth.  Contraction  of  the  neoplasm,  drawing  on  the 
surrounding  parts,  especially — through  the  ligamenta  suspen- 
soria — on  the  corium,  is  evidently  its  cause.  At  first  the  skin 
is  merely  slightly  dragged  upon,  so  that  dimpling  is  only 
appreciable  on  pinching  of  a  cutaneous  fold ;  subsequently  a 
permanent  dimple  is  produced,  and  later  on  puckering.  This 
condition  is  of  much  greater  diagnostic  value  than  detraction  of 
the  nipple  ;  since  but  few  morbid  conditions,  other  than  cancer, 
produce  it.     Many  surgeons  regard  it  as  an   infallible  sign  of 


DIFFERENTIAL    DIAGNOSIS. 


OJ' 


cancer.  Velpeau  especially  insists  upon  this.  Herein  I  am 
convinced  they  are  mistaken  ;  for  I  have  seen  several  marked 
instances  of  it  in  association  with  chronic  mastitis  ;  and  it  has 
also  been  noticed  in  cases  of  chronic  abscess. 

Discharge  from  the  Nipple.—  Discharge  from  the  nipple  is 
met  with  under  a  great  variety  of  conditions ;  but  it  is  not  of 
common  occurrence  in  connection  with  cancer.  Gross  estimates 
that  it  is  present  only  in  about  7  per  cent,  of  all  cancer  cases. 
When  it  does  occur,  it  is  often  the  earliest  symptom  of  the 
disease,  attracting  attention  even  before  the  cancerous  growth 
itself  Under  these  circumstances  the  discharge  is  never  abun- 
dant— seldom  does  it  amount  to  more  than  a  few  drops.  The 
fluid  may  be  straw-coloured,  sanious  or  of  watery  aspect ;  but 
occasionally  it  presents  a  mucoid  or  lactescent  appearance. 

Its  formation  is  due  to  a  kind  of  pseudo-secretion,  associated 
with  hyperplasia  of  the  glandular  epithelia,  together  with  the 
congestion  and  increased  vascularity  that  always  accompany 
cancer.  Discharge  from  the  nipple  is  also  met  with  in  connec- 
tion with  other  neoplasms  besides  cancer;  and  it  not  unfre- 
quently  occurs  in  the  abscence  of  any  mammary  neoplasm 
whatever.  With  the  ordinary  solid  tumours,  such  as  sarcoma 
and  fibro-adenoma,  it  occurs  about  as  often  as  with  cancer.  No 
form  of  mammary  disease  more  frequently  induces  it  than  the 
cystic,  and  it  is  especially  apt  to  occur  when  intra-cystic  villous 
growths  are  present.  Under  these  circumstances  the  discharge 
is  usually  blood-stained.  Colostrum-like  fluid  is  also  often  dis- 
charged from  the  nipple  in  connection  with  unhealthy  states 
of  the  gland,  correlated  with  disease  of  the  pelvic  organs,  and 
sometimes  in  connection  with  menstruation.  Abnormal 
stimuli  to  the  gland,  especially  such  as  are  protracted  and  of 
low  intensity,  are  apt  to  excite  secretory  activity. 

S    II. Differential  Diagnosis. 

The  differential  diagnosis  of  mammary  cancer  is  one  of 
the  most  important  questions  that  a  surgeon  can  have  to  decide; 
and  it  is  often  a  question  of  the  greatest  difficulty,  requiring  for 


340  CLINICAL    FEATURES    OF    MAMMARY    CANCER. 

its  solution  skill  and  knowledge  of  the  highest  order.  It  must 
be  recollected  that  nearly  all  the  difficulties  to  be  encountered 
appertain  to  the  early  stages  of  the  disease.  No  conditions, 
likely  to  be  confounded  with  cancer,  are  more  difficult  to  dis- 
criminate from  it,  than  certain  chronic  inflammatory  swellings 
(the  indiiratio  benignn  of  the  old  surgeons)  and  cold  abscesses. 
Two  sources  of  error  are  here  possible  ;  either  of  these  affections 
may  be  mistaken  for  cancer,  or  vice  versa.  Fortunately  such 
conditions  are  rather  uncommon,  although  not  so  rare,  that  the 
possibility  of  their  occurrence,  in  a  given  case,  can  ever  safely 
be  forgotten  ;  for  their  clinical  features  sometimes  so  closely 
resemble  those  of  cancer,  that  the  most  skilful  surgeons  have 
been  deceived.  In  making  the  differential  diagnosis  I  attach 
considerable  importance  to  the  presence  or  absence  of  pain 
and  tenderness  on  inanipidation,  for  cancers  at  this  stage  hardly 
ever  cause  pain,  nor  are  they  tender  ;  whereas  both  of  these 
symptoms  are  nearly  always  associated,  in  greater  or  lesser 
degree,  with  chronic  inflammatory  lesions.  On  the  other  hand, 
dimpling  of  the  skin,  although  it  cannot  be  relied  on  as  an 
absolute  criterion  of  cancer,  is  nevertheless  much  more  fre- 
quently associated  with  the  latter  than  with  chronic  inflamma- 
tory conditions.  The  margins  of  cancers  are  generally  more 
nodular,  and  feel  better  defined,  than  those  of  most  inflamma- 
tory tumours.  The  latter  seldom  attain  the  extreme  hardness 
of  the  former.  Enlarged  veins  visible  through  the  overlying  in- 
tegument are  suggestive  of  chancer;  but  the  presence  of  a  similar 
swelling  in  the  opposite  breast  is  against  it.  The  presence 
of  slight  cedematous  swelling  of  the  skin  over  the  tumour  points 
strongly  to  inflammation.  Another  fact  of  great  importance  to 
remember  in  making  the  differential  diagnosis  is,  that  neo- 
plasms very  rarely  take  origin  in  connection  with  lactation, 
whereas  most  inflammatory  tumours  do.  In  doubtful  cases  an 
exploratory  incision  into  the  tumour  may  be  made ;  but  even 
then  the  naked  eye  appearances  sometimes  mislead,  so  that 
when  necessary  the  microscope  must  also  be  invoked. 

The  conditions  I  have  seen  most    frequently  mistaken   for 


DIFFERENTIAL    DIAGNOSIS.  34 1 

cancer  are  cJiro)iic  mastitis,  chronic  tubercular  mastitis  and  cold 
abscess.     Of  each  of  these  I  will  give  a  typical  instance. 

(i)  A  large,  obese,  healthy  looking  woman,  aged  57,  the  mother  of  two 
children,  with  a  lump  in  her  left  breast  of  seven  years'  duration.  There  was 
no  history  of  any  previous  injury  or  disease  of  the  part.  Her  previous  health 
had  been  very  good  ;  there  was  no  family  history  of  cancer  or  tubercle.  On 
examination  I  found,  near  the  periphery  of  the  axillary  segment  of  her  left 
breast,  a  very  hard  nodulated  mass,  the  size  of  a  tangerine  orange.  The 
breasts  were  voluminous,  and  the  tumour  was  covered  by  a  thick  layer  of  fat. 
The  overlying  skin  was  adherent  and  dimpled,  but  the  tumour  was  movable 
on  the  subjacent  parts,  and  the  nipple  was  normal.  There  was  no  pain  or 
tenderness.  Several  of  the  axillary  glands  were  enlarged.  -  In  this  case  all 
the  indications  of  mammary  cancer  were  present,  with  the  exception  of 
retraction  of  the  nipple,  which  was  hardly  to  be  expected,  considering  the 
peripheral  situation  of  the  neoplasm.  Before  proceeding  to  amputation  and 
clearance  of  the  axilla,  I  made  an  exploratory  incision  into  the  tumour, 
which  presented  a  dense,  whitish,  fibroid  aspect,  just  like  that  of  ordinary 
scirrhus.  On  examination  after  removal,  the  diseaseci  area  looked  very  like 
cancer ;  but  on  section  it  seemed  rather  less  hard  and  crisp  than  scirrhus 
usually  is  ;  moreover,  it  did  not  cup,  and  it  was  juiceless.  The  enlarged 
axillary  glands  presented  no  signs  of  cancer.  These  indications  induced  me 
to  submit  the  tumour  to  careful  microscopical  examination,  the  result  of 
which  was,  that  it  was  seen  to  be  composed  mainly  of  dense,  white  fibrous 
tissue,  containing  numerous  nuclei,  in  which  a  few  acinous  and  tubular 
gland  structures  were  here  and  there  embedded.  When  last  seen,  about 
three  years  after  the  operation,  the  patient  was  in  excellent  health,  and 
free  from  any  return  of  the  disease.  It  was  a  clear  case  of  simple  chronic 
mastitis.  Here  the  unusual  absence  of  pain  and  tenderness,  together  with 
the  presence  of  dimpling  of  the  skin,  and  all  the  usual  symptoms  of  cancer, 
prevented  the  recognition  of  the  real  nature  of  the  disease. 

(2)  I  was  requested  by  a  medical  friend  to  see  an  unmarried  lady,  aged 
40,  with  a  swelling  in  her  breast  of  some  months'  duration,  which  she  attri- 
buted to  an  accidental  blow  from  a  child's  elbow.  On  examination  I  found, 
near  the  periphery  of  the  axillary  part  of  her  Jeft  breast,  a  nodular  lump,  the 
size  of  a  marble,  surrounded  by  irregular,  ill-defined  thickening  and  indura- 
tion. Although  the  lump  was  hard,  yet  the  degree  of  induration  seemed  to 
me  to  fall  short  of  that  usually  associated  with  scirrhous  cancer.  The  tumour 
was  painful,  and  on  manipulation  decidedly  tender.  The  nipple  was  stunted 
and  transversely  grooved,  but  both  were  alike  in  these  respects,  and  neither 
was  retracted.  The  skin  over  the  tumour  was  decidedly  drawn  upon,  so 
that  when  a  cutaneous  fold  was  pinched  up  it  dimpled  ;  but  the  tumour  was 
movable  on  the  subjacent  parts.  The  adjacent  axillary  glands  were  enlarged. 
I  also  detected  slight  lobular  thickening  in  the  opposite  breast.  The  patient 
had  chronic  cough,  with  a  small  amount  of  muco-purulent  expectoration,  and 
moist  rales  could  be  heard  over  the  upper  lobe  of  her  left  lung.  In  early 
adult  life  she  had  hsemoptysis,  and  subsequently  for  many  years  active 
phthisical  disease.     Some  years  ago,  however,  the  disease  became  quiescent, 


342  CLINICAL    FEATURES    OF    MAMMARY    CANCER. 

and  her  general  health  subsequently  greatly  improved.  Three  of  her  sisters 
had  died  of  phthisis.  Under  these  circumstances — relying  mainly  on  the 
pain  and  tenderness  of  the  swelling,  the  comparative  rapidity  of  its  forma- 
tion, its  ill-defined  margins  and  moderate  hardness,  as  well  as  the  slight 
lesions  in  the  opposite  breast — I  was  able  to  assure  the  patient  that  the 
tumour  was  almost  certainly  not  cancerous.  Moreover,  relying  on  the 
presence  of  tubercular  disease  in  the  lungs,  and  the  history  of  it  in  her 
family,  I  expressed  the  opinion  that  in  all  probability  it  was  also  of  tuber- 
cular origin,  and  recommended  local  and  general  anti-tubercular  treat- 
ment. I  was  then  for  the  first  time  informed  that  the  lady  had  previously 
consulted  a  medical  man  elsewhere,  who  had  pronounced  her  disease  to  be 
cancerous,  and  had  made  every  arrangement  for  amputating  the  breast 
the  following  week.  I  consequently  sent  this  gentleman  a  polite  note,  stat- 
ing the  circumstances,  and  what  I  had  recommended.  He  wrote  a  huffy 
letter  to  the  patient's  friends,  making  light  of  my  diagnosis  and  suggestions 
for  treatment ;  recommending  that  the  operation  should  nevertheless  be  pro- 
ceeded with  as  arranged,  and  deprecating  the  painful  predicament  in  which 
they  were  placed.  Fortunately  this  advice  was  not  followed,  and  after  a  few 
months'  treatment  the  disease  entirely  disappeared. 

(3)  I  witnessed  the   following  instructive  case  at  the  Pitie 
Hospital  in  Paris  in  1879. 

A  healthy-looking  multipara,  aged  30,  applied  to  Verneuil  on  account  of 
a  mammary  tumour  of  six  months'  duration,  which  she  first  noticed  about 
a  month  after  her  last  confinement.  There  was  no  history  of  cancer  in 
her  family.  On  examination  there  was  found,  deeply  seated  in  her  left 
breast,  an  exceedingly  hard,  irregularly  shaped  mass,  about  the  size  of  an 
orange.  At  one  spot  the  tumour  was  softer  than  elsewhere,  and  gave 
indications  of  indistinct  fluctuation.  The  adjacent  axillary  glands  were 
enlarged.  The  nipple  was  not  retracted,  nor  was  the  overlying  skin 
dimpled  ;  and  there  was  only  slight  pain  and  tenderness.  Basing  his 
remarks  on  this  case,  the  learned  professor  gave  to  the  large  assembled 
class  an  eloquent  address  on  the  differential  diagnosis  of  mammary  cancer, 
with  special  reference  to  its  discrimination  from  cold  abscess.  He  con- 
cluded from  the  extreme  hardness  of  the  tumour  and  the  enlargement  of 
the  axillary  glands,  that  the  case  before  them  was  an  undoubted  example  of 
scirrhus,  although  several  of  the  usual  clinical  features  were  wanting.  In 
accordance  with  this  view,  he  proceeded,  before  the  whole  class,  to  amputate 
the  breast  with  the  thermo-cautery  knife.  In  the  middle  of  the  operation  a 
large  abscess  cavity  was  opened,  out  of  which  quite  a  considerable  quantity 
of  thick  yellow  pus  gushed  out.  The  professor  looked  grave  and  puzzled. 
He  proceeded  with  his  operation,  however,  including  removal  of  the  axillary 
glands.  The  patient  made  a  complete  and  rapid  recovery.  Microscopical 
examination  of  the  indurated  cyst  wall  revealed  only  signs  of  inflammation 
— viz.,  abundant  fibrous  tissue  densely  infiltrated  with  small  round  cells,  &c. 

It  would  be  easy  to  multiply  cases  like  the  foregoing ;  and 

illustrative    specimens    may   be    found    in    most    pathological 


DIFFERENTIAL    DIAGNOSIS.  343 

museums.  They  show  that,  under  certain  circumstances,  even 
the  most  experienced  may  sometimes  be  mistaken. 

Indurations  of  the  breast,  resembling  cancer,  due  to  in- 
terstitial mastitis,  are  sometimes  caused  by  syphihs ;  these 
disappear  under  appropriate  treatment. 

Certain  cysts,  especially  when  tense,  deeply  seated  and 
unilocular,  occasionally  acquire  stony  hardness,  and  may  other- 
wise simulate  cancer ;  some  other  forms  of  cystic  disease  may 
also  now  and  then  be  met  with  that  much  resemble  cancer.  It 
is  hardly  possible  for  anyone  who  has  made  himself  familiar 
with  the  cardinal  features  of  sarcoma,  fibro-adenoma,  tubular 
cancer,  villous  papilloma,  lobular  hypertrophy  and  the  ordinary 
forms  of  cystic  disease,  to  mistake  these  conditions  for  scirrhus  ; 
at  any  rate,  nothing  special  need  here  be  said  as  to  the  differen- 
tial diagnosis  in  such  cases. 


344 


CHAPTER    XIII. 
The  Treatment  of  Acinous  Cancer. 


S     I. Operative. 

Pathological  doctrine  points  so  emphatically  to  the 
possibility  of  cancer  being  curable  by  sufficiently  thorough 
operations,  that  no  one,  now-a-days,  doubts  the  propriety  of 
such  proceedings.  Instead  of  discussing  this  question,  modern 
surgeons  have  concentrated  their  attention  almost  exclusively 
upon  devising  better  methods  for  completely  eradicating  the 
disease.  Earlier  and  more  thorough  operations  than  have 
hitherto  been  customary  are  now  the  order  of  the  day. 

In  the  operative  treatment  of  mammary  cancer  from  this 
standpoint,  I  think  it  must  be  admitted  that  British  surgery 
has  not  taken  the  leading  position  to  which  it  was  entitled. 
This  is  the  more  to  be  regretted,  because  the  modern  thorough 
operation  is  unquestionably  of  English  origin.  All  its  funda- 
mental essentials  were  clearly  set  forth,  with  illustrative  cases, 
in  a  paper — remarkable  for  its  keen  insight  and  sound  judg- 
ment— communicated  to  the  London  Medico-Chirurgical  Society 
by  Charles  Moore  in  1867.'  Strange  to  relate,  notwithstanding 
its  completeness,  the  influence  of  this  remarkable  communica- 
tion on  contemporary  surgical  practice  was  almost  nil — so 
difficult  is  it,  in  the  hurly-burly  of  intellectual  strife,  to  discrimi- 


'  "  On  the  Influence  of  Inadequate  Operations  on  the  Theory  of  Cancer,"  Med. 
Chir.   Trans.,  vol.  i. ,  p.  245. 


OPERATIVE.  345 

nate  real  merit.  In  spite  of  it,  British  surgeons  continued,  as 
heretofore,  to  be  satisfied  with  partial  operations,  in  which  the 
axillary  glands  were  seldom  removed.  Fortunately  the  seed 
that  failed  here,  germinated  elsewhere.  The  excellent  results 
obtained  in  Germany  by  Moore's  method,  at  length  compelled 
reconsideration  of  the  subject.  Its  reintroduction  into  this 
country  dates  from  the  publication  of  Banks'  experience  in 
1882;^  while  in  the  United  States  the  practice  of  Gross  has 
tended  to  the  same  end.^ 

(a)  Anatotnico- P athological  Memorabilia. 

The  requisites  of  a  satisfactory  thorough  operation  for 
mammary  cancer  comprise  complete  removal  of  the  local 
disease,  and  of  the  entire  breast,  as  well  as  of  the  axillary 
glands. 

At  first  sight  complete  extirpation  seems  to  be  a  very 
simple  affair ;  yet,  nothing  is  more  certain,  than  that  in  the 
great  majority  of  such  operations,  even  as  done  by  experienced 
surgeons,  this  result  is  not  obtained — fragments  of  the  disease 
and  of  the  breast  are  almost  invariably  left  behind.  Of  course, 
operations,  thus  conducted,  can  never  be  really  curative.  Hence 
the  supreme  importance  of  paying  attention  to  certain  ana- 
tomico-pathological facts  — now  generally  neglected — without 
knowledge  of  which  it  is  impossible  to  perform  the  operation 
effectually.  The  enumeration  of  these  will  necessitate  some 
repetitions,  for  which,  on  account  of  the  importance  of  the 
subject,  I  beg  to  be  excused.     They  are  briefly  as  follows  : — 

(i)  In  operating  for  cancer  the  cardinal  consideration  to  be 
borne  in  mind  is,  that  the  ivJiole  disease  must  be  removed,  since 
the  smallest  fragment  left  behind  will  suffice  to  originate  a  new 
growth.  To  do  this  effectually,  accurate  knowledge  of  the 
disposition  of  the  local  disease  is  essential.     On  careful  exami- 


-  "  Some  Results  of  the  Operative  Treatment  of  Cancer  of  the  Breast,"  Edin. 
1882. 

^  Intey national  Journal  of  Medical  Sciences ^  April,  1888. 


346  TREATMENT    OF    ACINOUS    CANCER. 

nation  of  the  periphery  of  the  primary  neoplasm   it  will    be 
found,  that  the  passage  from  the  diseased  to  the  healthy  tissues 
is  by  no  means  sharply  defined ;  the  irregularly  growing  edge  of 
the  cancer  is,  so  to  speak,  dovetailed  into  the  surrounding  pre- 
existing structures.     On  this  subject   Astley  Cooper  remarks : 
"  I  would  observe  that  the  scirrhous  tumour  is  not  all  of  the 
disease  ;  there  are  roots  which  extend  to  a  considerable  distance, 
and  those  who  gave  this  disease  the  name  of  cancer  probably 
knew  more  of  its  nature  than  we  are  disposed  to  give  them 
credit  for.     It  is  supposed  by  some  that  this  name  was  given 
on    account  of  the  appearance  of  the   surrounding   veins.       I 
should  say  that  it  was  from  the  appearances  on  dissection  rather 
than    from   anything  without.     When   you  dissect  a  scirrhous 
tumour,  you  see  a  number  of  roots  proceeding  to  a  considerable 
distance  ;    and   if  you   remove  the  tumour  only,  and  not  the 
roots,  there  will  be  little  advantage  from  the  operation."     This 
admirable  resume  of  the  subject  is  entirely  in  accord  with  the 
results  of  modern  research.     If  we  examine  the  growing  edge 
of  a  mammary  cancer  we  shall  find  that  one  way  in  which  the 
disease  progresses  is  by  the  continuous  centrifugal  extension  of 
epithelial  ingrowing  processes.     These  spread  most  rapidly  in 
the  directions  of  least  resistance,  which  are   usually   along  the 
adjacent  lymphatics  and  perivascular  sheaths.      These  Koster 
has  found  distended  with  cancer  cells.     Fine,  elongated,  cord-  ■ 
like   processes   of   cancerous   growth    thus    arise,   which   often 
extend  from  the  tumour  far  into  the  surrounding  tissues.     In 
connection  with  these,  nodular  growths   often   develop,  which 
to  the  naked  eye  may  appear  to  have  no  connection  with  the 
primary  tumour.     In  addition,  there  are  frequently  found  in  the 
vicinity  of  the  latter,  really  discontinuous  nodules,  which  are 
the    first   signs   of  regional    dissemination.     These   arise    from 
cellular  elements  detached  from  the  primary  tumour,  and  con- 
veyed   thence    by  the    lymphatics    or    veins,  or    by   their    own 
spontaneous  movements.     Such  is  the  great  abundance  of  the 
mammary  lymphatics,  and  the   freedom  of  their  anastomoses  ; 
that   from  a  single  primary  focus    the    disease   soon    spreads. 


OPERATIVE.  347 

Hence  the  paramammary  adipose  tissue,  the  skin  overlying  the 
vicinity  of  the  tumour,  and  the  sheath  of  the  pectoral  muscle 
are  quickly  invaded,  and  must  in  every  case  be  carefully  extir- 
pated. With  regard  to  the  paramammary  fibro-fatty  tissue, 
it  should  be  noted  that  it  forms  a  thick  layer  anteriorly,  while 
posteriorly  it  is  generally  defective.  The  channels  along  which 
the  disease  most  readily  spreads  into  the  anterior  paramammary 
fat  and  thence  to  the  skin,  are  the  lymphatics  accompanying  the 
peripheral  processes  of  the  gland  ;  these,  with  their  accompany- 
ing lymphatics,  ultimately  come  into  close  relationship  with 
the  skin,  through  the  ligament  a  suspejisoria  of  Cooper,  within 
which  they  are  contained.  Hence  the  attempt  to  save  the 
integument  overlying  cancerous  tumours  is  a  pernicious  error ; 
in  every  case  it  should  be  freely  excised.  Posteriorly,  all  that 
intervenes  between  the  concave  base  of  the  gland  and  the 
subjacent  pectoral  fascia,  is  some  loose  areolar  tissue.  In  this 
peripheral  processes  of  the  gland,  with  their  accompanying 
lymphatics,  &c.,  are  always  to  be  found  ;  which  not  only  adhere 
to  the  subjacent  muscular  fascia,  but  often  penetrate  it,  and 
even  become  embedded  in  the  muscle  itself.  In  cases  of 
mammary  cancer  these  structures  are  nearly  always  diseased  ; 
and  at  ordinary  operations  they  are  almost  invariably  left 
behind.  Hence  recurrences  soon  follow.  To  obviate  this 
Heidenhain  recommends  that  the  fascia  over  the  pectoral 
muscle,  together  with  a  layer  of  the  subjacent  muscular  sub- 
stance, should  be  excised  in  every  case  ;  and  his  recommenda- 
tion certainly  ought  to  be  regarded  as  an  essential  feature  of 
the  operation.  When  the  muscle  itself  is  obviously  diseased, 
Heidenhain  recommends  that  the  whole  of  it  should  be  extir- 
pated. This  I  think  is  unnecessary.  It  is  nearly  always  the 
sternal  part  alone  that  is  invaded  ;  and  it  is  then  sufficient  to 
excise  this,  without  interfering  with  the  clavicular  part.  This 
is  justified  on  anatomical  grounds  ;  because,  as  I  have  repeatedly 
convinced  myself  by  dissection,  these  two  parts  of  the  muscle 
are  usually  quite  separate,  except  at  their  insertion  into  the 
humerus.  Excision  of  the  sternal  part  of  the  muscle  causes 
very  little  deformity,  and  no  appreciable  loss  of  power. 


34^  TREATMENT    OF    ACINOUS    CANCER. 

(2)  In  cases  of  mammary  cancer  the  wJiole  gland  is  diseased, 
and  must  therefore  be  removed.  Its  secretory  cells  are  unduly 
numerous,  and  they  everywhere  show  signs  of  excessive  pro- 
liferative activity ;  while  the  peri-acinous  connective  tissue  is 
much  increased  and  infiltrated  with  small  round  cells.  This 
clearly  implies  that  the  abnormal  cellular  activity,  which  at  a 
given  spot  culminates  in  cancer,  affects  in  a  less  degree  the 
adjacent  epithelia  of  the  part  for  a  considerable  extent.  It  is 
impossible  to  doubt  that  parts  in  such  a  condition  are  more 
prone  to  originate  cancers,  than  perfectly  normal  structures. 
Heidenhain  is,  I  believe,  right  in  maintaining  that  proliferating 
acini  of  this  kind,  left  behind  at  the  primary  operation,  are 
the  germs  whence  most  late  recurrences  arise.  In  order  to  effect 
the  removal  of  the  entire  gland,  certain  facts,  that  I  will  now 
proceed  to  mention,  must  be  kept  steadily  in  view.  The  female 
breast  is  normally  a  very  imperfectly  integrated  organ ;  like  the 
lachrymal  and  salivary  glands,  its  constituent  lobules,  instead 
of  being  compacted  together  in  a  small  space,  are  generally 
widely  diffused  ;  and  often  some  of  them  are  completely  seques- 
trated. On  this  subject  Astley  Cooper  remarks  :  "  The  margins 
of  the  breast  do  not  form  a  regular  disc,  but  the  secreting  struc- 
ture often  projects  into  the  surrounding  fibrous  and  adipose 
tissue,  so  as  to  produce  radii  from  the  nipple  of  very  unequal 
lengths ;  hence  a  circular  sweep  of  the  knife  cuts  off  many  of 
its  projections,  spoils  the  breast  for  dissection,  and,  in  surgical 
operations,  leaves  much  of  the  disease  unremoved." 

The  ordinary  anatomical  description  of  the  breast,  as  a 
flattened  circular  mass,  is  certainly  very  misleading.  The 
truth  is,  as  Hennig  has  so  well  shown,  the  fully  developed 
female  mamma  has  normally  a  tricuspid  form  ;  two  of  the 
cusps  project  toward  the  axilla — an  upper  and  a  lower  one 
— and  the  other  towards  the  sternum.  The  upper  of  these 
two  axillary  mammary  extensions  is  usually  prolonged  round 
the  border  of  the  pectoralis  major  muscle,  right  into  the  axilla  ; 
and  the  same  occasionally  happens  with  the  lower  one.  The 
sternal  prolongation  reaches    nearly  as  far  as  the  edge  of  the 


OPERATIVE.  349 

sternum — at  the  level  of  the  fourth  cartilage — and  even  oc- 
casionally overlaps  it.  In  the  ordinary  operation  of  ampu- 
tation of  the  breast,  these  processes  are  almost  invariably  cut 
off  and  left  behind.  Though  commonest  in  the  axillary  and 
sternal  regions,  similar  smaller  peripheral  processes  spring  from 
other  parts  of  the  surface  of  the  gland,  and  radiate  in  the 
paramammary  tissues.  It  has  been  previously  mentioned  that 
those  arising  from  the  anterior  surface  of  the  gland  come  into 
close  relationship  with  the  skin  ;  while  those  that  originate  from 
its  posterior  surface  come  into  contact  with  the  pectoral  muscle 
and  its  fascia.  Their  precise  limits  are  ill  defined  and  vary  in 
different  individuals ;  as  a  rule,  however,  they  do  not  extend 
higher  up  than  the  second,  nor  lower  down  than  the  sixth 
interspace. 

(3)  In  the  mammary  region  completely  isolated  super- 
numerary mammary  structures  are  of  frequent  occurrence.  I 
have  elsewhere  shown  that  these  redundant  structures  are  very 
prone  to  originate  neoplasms — 14  per  cent,  of  all  so-called 
adenomas  of  the  breast,  and  9*8  per  cent,  of  all  its  cancers,  arise 
in  this  way.  Two  varieties  of  the  condition  may  be  recognised 
— a  commoner  one,  which  is  simply  the  result  of  sequestration  ; 
and  a  rarer  one  of  atavistic  origin — true  polymastia.  Structures 
of  this  kind,  left  behind  after  operation,  sometimes  originate 
recurrences.  In  order  to  be  able  to  remove  them  effectually, 
their  distribution  must  be  studied.  This  is  best  done  by  noting 
the  positions  of  the  neoplasms  that  have  sprung  from  them. 
Of  29  such  cases,  in  15  the  tumours  were  axillary,  in  8  they 
were  sternal^  and  in  6  they  were  situated  above  the  breast. 

In  this  connection  it  may  be  mentioned  that  cancerous 
tumours  are  more  prone  to  develop  in  some  parts  of  the  gland 
than  in  others.  The  periphery,  for  instance,  is  a  much  commoner 
seat  of  the  disease  than  its  central  part.  Of  132  cases  under 
my  observation,  in  90  {6%  per  cent.)  the  tumour  was  peripheral, 
and  in  42  (32  per  cent.)  central.  Most  of  the  peripheral  tumours 
are  met  with  at  this  upper  and  axillary  parts  of  the  gland. 

(4)  Such  is  the  great  tenacity  of  life,  and  the  wonderful  pro- 


350  TREATMENT    OF    ACINOUS    CANCER. 

liferative  power,  of  even  the  most  diminutive  fragments  of  cancer, 
that  care  should  be  taken  to  avoid  the  dissemination  of  such 
elements  in  the  wound  during  the  operation,  lest  they  consti- 
tute fresh  centres  of  disease.  Hence,  in  doing  the  operation, 
no  actually  morbid  texture  should  be  exposed  ;  and  it  is  desir- 
able not  only  to  avoid  any  incision  into  the  tumour,  but  even 
the  very  sight  of  it.  Where  these  precautions  are,  unfortun- 
ately, of  no  avail,  the  wound  must  be  well  washed  out  with  a 
strong  solution  of  chloride  of  zinc  (4c  gr.  to  i  oz.),  so  that  any 
fragments  of  the  disease,  disseminated  there,  may  be  destroyed."* 
(5)  In  extirpating  mammary  cancer,  it  was  formerly  cus- 
tomary for  surgeons  to  open  and  clear  out  the  axilla  only 
when  its  glands  were  obviously  diseased.  The  result  of 
this  practice  was,  that  in  many  cases  the  disease  reappeared 
after  operation  in  the  axilla  alone,  while  the  mammary  region 
remained  free.  As  previously  mentioned,  it  happened  thus  in 
17  per  cent,  of  the  cases  under  my  observation.  Moreover, 
Gross^  has  shown  that  glandular  recurrences  are  more  frequent, 
by  27  per  cent.,  when  the  breast  alone  is  removed,  than  when 
it  is  extirpated  together  with  the  axillary  contents.  To 
obviate  this,  the  practice  of  clearing  out  the  axilla  in  every 
case  destined  for  operation — whether  the  glands  were  obviously 
affected  or  not — was  inaugurated.  Gussenbauer  and  Kuster 
on  the  Continent  (1881),  and  Banks  in  this  country  (1882),  were 
the  pioneers  of  this  improvement,  which  now  constitutes  an 
essential  part  of  every  thorough  operation.  The  necessity  of 
clearing  the  axilla  is  further  shown  by  the  fact,  that  in  the 
immense  majority  of  cases  in  which  the  axillary  glands  have 
been  histologically  examined  after  removal,  they  have  been 
found  to  be  invaded  by  the  disease,  and  this,  although  in  many 
cases  careful  clinical  examination,  before  operation,  had  failed 
to  detect  their  morbid  condition. 


*  A  further  reason  for  these  precautions  has  been  furnished  by  Verneuil  {J?Jv.  de 
Chtr.,  t.  ix.,  Oct.  10,  1889),  who  has  shown  that  the  wounds  resultini^  from  the 
removal  of  malignant  tumours  are  frequently  infected  by  jiathogenic  microbes 
derived  from  these  tumours. 

•  Interna/,  /our.  Med.  .Sn'.,  April,  1888,  p.  347. 


OPERATIVE.  351 

In  clearing  the  axilla,  the  glands  should  be  removed  as 
far  as  possible  en  masse,  together  with  the  fatty  tissue,  &c.,  in 
which  they  are  embedded,  and  it  is  important  not  to  sever  the 
bridge  of  tissue  intervening  between  this  part  and  the  breast,  as 
it  contains  the  axillary  process  of  the  mamma,  together  with 
the  chief  mammary  lymphatics  and  some  blood-vessels,  all  of 
which  it  is  desirable  to  remove  en  masse  with  the  rest  of  the 
implicated  mammary  structures. 

It  is  in  the  vicinity  of  the  inner  axillary  wall  that  the 
fewest  obstacles  to  surgical  proceedings  are  encountered.  Here 
the  only  important  structure  likely  to  be  injured,  is  the  long 
thoracic  nerve,  which  courses  nearly  vertically  downwards,  on 
the  serratus  magnus  muscle,  which  it  supplies.  Fortunately 
it  is  in  this  region  that  the  glands  first  affected  in  mammary 
cancer  are  usually  to  be  found  ;  they  lie  on  the  chest  wall,  at  the 
lower  part  of  the  inner  axillary  boundary.  The  axillary  tail 
of  the  mamma  is  close  by,  and  may  be  mistaken  for  them. 
The  thickened  cord  that  can  sometimes  be  felt  passing  from 
this  part  of  the  axilla  to  the  breast  is  hardly  ever  due  to  can- 
cerous lymphatics,  but  to  the  pedicle  of  the  axillary  mammary 
process. 

In  the  neighbourhood  of  the  outer  axillary  wall  are  the 
axillary  blood-vessels  and  nerves — the  artery  between  the  nerve 
cords,  with  the  vein  on  its  inner  side,  where  it  is  joined  by  several 
large  branches.  These  are  often  severed  when  removing  the 
glands,  and  unless  care  is  taken  they  may  be  cut  so  short  as 
to  render  the  application  of  ligatures  impossible.  In  such  an 
event  the  axillary  vein  must  be  ligatured  above  and  below  the 
point  at  which  the  severed  branch  joins  it,  and  divided  between 
the  ligatures,  just  as  if  the  vein  itself  had  been  wounded.  I 
have  seen  this  done  several  times,  without  any  other  ill  result 
than  slight  transient  cedema  of  the  hand.  In  close  relationship 
with  the  inner  side  of  the  axillary  vein  is  a  group  of  glands, 
which  are  usually  affected  soon  after  the  above-mentioned  group 
with  which  they  freely  communicate.  They  may  extend  as  high 
up  as  the  clavicle,  or  even  higher.     In  this  connection  it  should 


352  TREATMENT    OF    ACINOUS    CANCER. 

be  remembered,  that  when  the  upper  limb  is  raised  from  the 
side,  as  usually  happens  in  the  course  of  this  operation,  the  head 
of  the  humerus  is  apt  to  project  and  displace  the  lar^e  vessels 
downwards  towards  the  chest  wall. 

At  the  extreme  summit  of  the  axilla — in  the  space  identi- 
fied in  Germany  with  the  name  of  Mohrenheim — between  the 
clavicle  and  the  upper  border  of  the  pectoralis  minor  muscle, 
a  few  lymphatic  glands  are  placed,  which  receive  branches 
directly  from  the  breast.  These  sometimes  require  extirpation, 
which  can  best  be  done  after  removal  of  the  sternal  part  of  the 
pectoralis  major  muscle.  In  the  interval  between  the  pec- 
toralis major  and  deltoid  muscles,  just  below  the  clavicle,  a 
few  diseased  glands  may  also  be  met  with.  These  regions 
should  always  be  explored. 

In  clearing  out  the  axilla  it  is  desirable  to  avoid  trenching 
on  the  posterior  wall  as  much  as  possible,  especially  at  its  lower 
and  outer  parts,  as  here  the  large  subscapular  blood  vessels  and 
nerves  (to  the  teres  major  and  latissimus  dorsi)  lie. 

{U)  The  Operation. 

The  following  operation  is  designed  to  fulfil  the  above  indica- 
tions. So  far  as  I  know,  it  is  not  exactly  like  any  other ;  but 
most  modern  thorough  operations  have  much  in  common.  Sup- 
posing the  breast  to  be  of  medium  size,  the  tumour  compact  and 
central,  the  incision  is  commenced  in  the  median  line  over  the 
sternum,  at  the  level  of  the  fourth  costal  cartilage,  along  which 
it  passes  outwards  to  the  nearest  part  of  the  periphery  of  the 
cutaneous  area,  overlying  the  disease,  which  it  is  desired  to 
remove.  This  is  generally  a  circular  area,  several  inches  in 
diameter,  which  includes  the  nipple  and  areola.  Thence  the 
incision  is  continued  along  the  lower  half  of  the  periphery  of 
this  area  to  its  axillary  side,  whence  it  passes  over  the  anterior 
axillary  border  to  the  top  of  the  axilla.  The  next  step  is  to 
separate  the  skin  from  the  subjacent  fatty  tissue,  by  careful 
dissection,  throughout  the  whole  length  of  the  thoracic  part  of 


OPERATIVE.  353 

the  lower  lip  of  this  incision — to  the  extent  of  an  inch  or  more. 
The  more  thoroughly  this  is  done  the  better,  short  of  impairing 
the  vitality  of  the  skin.  The  cutaneous  area  to  be  removed  with 
the  diseased  breast  should  now  be  completely  separated  from 
the  adjacent  integument,  by  carrying  the  knife  round  its 
unsevered  upper  periphery.  The  upper  lip  of  the  thoracic 
part  of  the  incision  must  next  be  separated  from  the  subcuta- 
neous fatty  tissue  to  near  the  axilla,  just  as  was  done  with  the 
lower  lip. 

The  periphery  of  the  part  to  be  removed  being  thus  defined, 
its  separation  may  be  commenced  by  raising  its  upper  and  inner 
margins.  The  knife  should  then  be  sunk  slightly  into  the  sub- 
jacent pectoral  muscle,  and  by  dissection  the  whole  mass  must 
be  turned  outwards  towards  the  axilla,  until  it  remains  united 
with  the  latter  only  by  an  intervening  bridge  of  tissues,  which 
should  on  no  account  be  severed. 

Thus  the  whole  diseased  breast — embedded  in  its  fatty  cap- 
sule, together  with  the  overlying  skin  and  underlying  pectoral 
fascia — is  detached  from  its  bed.  This  concludes  the  first  stage 
of  the  operation. 

The  second  stage  comprises  the  removal  en  masse  of  the 
axillary  glands,  lymphatics,  &c.,  together  with  the  fatty  tissue 
in  which  these  are  embedded.  On  no  account  should  these 
structures  be  torn  away  piecemeal.  To  effect  this,  the  fascia 
lata  having  been  divided,  the  upper  flap  should  be  raised  and 
freely  separated  from  the  subjacent  structures  ;  but  there  is 
seldom  occasion  for  any  such  free  separation  of  the  lower  flap 
in  this  situation.  However,  should  this  be  requisite,  a  counter 
opening  must  be  made  for  drainage.  It  is  well  to  commence 
the  detachment  below,  and  to  work  upwards  along  the  chest 
wall  to  the  apex  of  the  axilla  ;  then  detach  from  the  great 
vessels,  and  finally  from  the  posterior  axillary  wall.  In  doing 
this  any  blood-vessels  requiring  division  should  be  included 
between  two  ligatures,  and  cut  through  between  them.  If  abso- 
lutely necessary,  even  the  axillary  vein  and  artery  may  be  treated 


23 


354  TREATMENT    OF    ACINOUS    CANCER. 

in  this  way,  often  without  ill  effect,  provided  that  the  occlusion 
is  below  the  level  of  the  circumflex  and  subscapular  branches.^ 

Much  more  extensive  operations  than  the  foregoing  have 
been  undertaken  by  German  surgeons,  who  have  not  hesitated 
to  extirpate,  in  addition,  one  or  both  pectoral  muscles,  the  outer 
part  of  the  clavicle,  and  even  in  certain  cases,  they  have  removed 
as  well  the  entire  upper  limb,  together  with  the  scapula.  When 
the  large  nerve  cords  are  involved,  as  well  as  the  blood  vessels, 
amputation  is  the  only  resort. 

The  only  contra-indications  to  operaiio7i  are  such  wide-spread 
local  or  lymph  gland  dissemination  as  would  render  impossible 
the  removal  of  the  entire  disease,  as  in  cases  of  cancer  e?i 
cuirasse  and  some  other  forms  of  diffuse  cancer  ;  and  of  course 
operation  is  contra-indicated  when  there  is  reason  to  suspect 
dissemination  of  the  disease  in  internal  organs. 

The  treatment  of  reairrent  cancer  should  be  conducted 
in  accordance  with  the  same  principles  as  for  the  primary 
disease. 

With  regard  to  the  technique  of  the  operation  the  following 
are  the  chief  points : — The  axilla  having  been  shaved,  the 
patient  is  placed  on  her  back,  and  the  shoulders  are  well  raised. 
The  surgeon  stands  on  the  same  side  as  the  breast  to  be  re- 
moved. Opposite  to  him  is  his  first  assistant.  His  second 
assistant  stands  at  the  patient's  shoulder  on  the  same  side  as 
the  disease;  he  has  charge  of  the  patient's  upper  limb,  and 
during  the  operation  he  must  keep  it  raised  and  manipulate  it 
as  required.  For  the  pectoral  part  of  the  operation  a  large 
stout  scalpel  should  be  employed  ;  but  for  the  axillary  part 
blunt-pointed  scissors  and  the  fingers  usually  suffice.  Bleeding 
vessels  should  be  seized  with  torsi -pressure  forceps  as  they 
present,  and  subsequently  ligatured  if  necessary.  On  approxi- 
mation of  the  flaps,  after  removal  of  the  diseased  mass,  it  will 


*  For  cases  in  which  both  the  axillary  artery  and  vein  were  divided,  without  any 
subsequent  ill  effects,  during  the  removal  of  axillary  tumours,  vide  McLeod's 
"Operative  Surgery  in  Calcutta,"  1885,  p.  152.  Also  Holmes' "  Syst.  Surgery," 
vol.  iii.,  1883,  article  "  Axilla,"  p.  887. 


OPERATIVE.  355 

generally  be  found  that  they  come  well  together,  notwithstanding 
the  free  removal  of  skin.  In  certain  cases,  where  the  flaps  are 
large  and  bulky  and  tend  to  fall  apart,  tension  may  be  relieved 
by  the  use  of  button  suttires.  The  most  convenient  of  these  are 
thin  leaden  discs  having  a  central  perforation,  and  two  small 
wings  laterally.  The  silver  wire  joining  two  buttons  passes 
through  these  central  apertures,  and  by  twisting  is  secured  to 
the  wings. 

When,  owing  to  the  free  removal  of  skin,  a  large  gap  re- 
mains, after  laying  down  the  flaps,  this  may  be  repaired  by 
skin  grafting,  after  the  method  of  Oilier^  and  Thiersch,  either  at 
the  time  of  the  operation,  or  a  few  weeks  afterwards.  The 
surface  to  be  grafted  must  be  quite  free  from  haemorrhage. 
Grafts  may  be  furnished  by  the  skin  of  any  part  of  the  body, 
but  they  are  usually  taken  from  that  of  the  thigh  or  arm.  The 
integument  of  the  selected  locality  having  been  sterilised,  is  put 
on  the  stretch  with  one  hand,  while  with  the  other,  a  broad 
razor  or  microscopic-section  knife  is  applied  flat-wise,  and  by 
a  series  of  to-and-fro  movements,  long  cutaneous  strips — about 
an  inch  broad,  embracing  the  entire  thickness  of  the  epidermis 
and  about  half  that  of  the  dermis — are  excised.  The  operation 
is  facilitated  by  keeping  the  knife  flooded  with  normal  salt 
solution  (3  per  cent.).  By  means  of  this  solution,  each  graft, 
as  soon  as  cut,  is  at  once  floated  on  to  the  sterilised  wound  sur- 
face to  which  it  is  to  be  applied.  In  effecting  the  transfer,  a 
camel's  hair  brush  and  a  mounted  needle  will  be  found  useful. 
The  grafts  should  lie  close  together  until  they  completely  cover 
the  wound.  Finally  they  are  covered  by  protective,  outside 
which  a  sterilised  dressing,  moistened  with  salt  solution,  and 
having  waterproof  material  over  it,  is  lightly  bound. 

Inasmuch  as  over  60  per  cent,  of  all  deaths  after  extirpation 
of  the  breast  for  cancer  are  due  to  septic  diseases,  it  is  obviously 
a  matter  of  vital  importance  to  utilise  the  best  means  for 
counteracting  these  baneful  influences  that  modern  science  has 
revealed.     To  this  end  the    importance  of  good  hygienic  con- 

"  "  Des  Greffes  Autoplastiques,"  Cong.  fr.  de  Chir.,  Rev.  de  Chir.,  1889,  p.  910. 


356  TREATMENT    OF    ACINOUS    CANCER. 

ditions — such  as  plenty  of  cubic  space,  efficient  ventilation  and 
drainage,  cleanliness,  good  feeding,  the  segregation  of  those  with 
open  wounds,  and  prompt  isolation  of  infective  cases — cannot  be 
too  strongly  insisted  upon.  But,  unfortunately,  these  powerful 
adjuncts  against  the  origin  and  spread  of  septic  diseases — under 
the  actual  conditions — of  themselves  seldom  suffice  to  entirely 
prevent  their  outbreak.  In  the  resources  of  modern  antiseptic 
surgery,  we  have,  however,  more  direct  means  for  combating 
them. 

It  has  been  shown  by  Lister  and  others  that  the  septic 
diseases,  which  so  frequently  arise  in  connection  with  wounds, 
are  due  to  infection  of  the  latter  by  microbes  ab  extra.  By 
means  of  various  agents,  capable  of  destroying  such  organisms, 
without  acting  injuriously  upon  the  tissues,  it  is  claimed  that 
these  wound -infection  diseases  may  be  entirely  prevented. 
The  substances  that  have  hitherto  been  chiefly  employed 
with  this  object,  are  carbolic  acid,  corrosive  sublimate,  double 
cyanide  of  mercury  and  zinc,  salicylic  acid,  iodoform,  boric 
acid,  &c.  Of  these,  carbolic  acid^  has  proved  to  be  the  most 
generally  useful  and  reliable.  It  is  employed  as  follows  : — 
The  cutaneous  area  of  the  field  of  operation — which  teems 
with  pathogenic  microbes — is  first  of  all  thoroughly  purified, 
by  sponging  it  for  some  minutes  with  i  in  20  watery  solu- 
tion of  the  acid.  The  instruments  to  be  used  during  the 
operation  are  kept  immersed  in  similar  solution.  The  surgeon 
and  his  assistants  wash  their  hands  in  i  to  40  solution  before 
commencing  the  operation,  and  a  special  supply  of  this  must  be 
provided  for  their  subsequent  use.  A  towel,  wrung  out  with 
I  in  20  solution,  and  having  under  it  waterproof  sheeting,  is 
arranged  so  as  to  border  the  lower  part  of  the  field  of  operation. 
A  basis  is  thus  formed  on  which  instruments,  &c.,  in  use  during 
the  operation,  may  be  temporarily  placed,  without  fear  of  con- 


"  Only  the  purest  forms  should  be  used,  as  these  are  more  soluble  and  less  irritat- 
ing than  impure  kinds.  The  absolute  phenol,  manufactured  by  Bowdler  and  Bicker- 
dyke,  of  Church,  near  Manchester,  is  recommended  by  Lister  as  one  of  the  best 
forms  for  surgical  purposes. 


OPERATIVE.  357 

tamination.  It  is  well  to  have  handy  a  large  piece  of  lint,  wrung 
out  with  I  in  40  solution,  for  temporarily  covering  the  thoracic 
wound  while  the  axilla  is  being  cleared.  Sponges  used  during 
the  operation  should  have  been  soaked  for  twenty-four  hours 
previously  in  i  in  20  solution  ;  this  renders  them  aseptic,  no 
matter  how  dirty  they  may  otherwise  be.  The  difficulty  in 
satisfactorily  cleansing  sponges  after  operations,  has  led  some 
surgeons  to  abandon  their  use  altogether.  Instead,  they  employ 
pads  of  various  antiseptic  materials,  which  after  use  are  burnt ; 
but  such  substitutes  are  much  less  efficient  than  sponges.^  For 
ligatures  the  materials  employed  are  asepticised  chromic  gut 
and  silk  (Chinese  twist),  the  latter  being  reserved  for  securing 
the  largest  vessels ;  they  should  be  steeped  in  i  in  20  solution 
before  use.  Of  the  various  substances  available  for  sutures, 
horsehair  and  silkworm  gut  are  the  best ;  they  are  fit  for  use 
after  having  been  immersed  for  some  time  in  i  in  20  solution. 
When  horsehair  is  employed,  double  threads  must  be  used,  as 
the  single  threads  are  not  strong  enough.  The  use  of  the  spray 
is  now  generally  abandoned,  consequently  before  closing  the 
wound,  at  the  conclusion  of  the  operation,  it  must  be  washed 
out  with  I  in  40  solution.  This,  of  course,  irritates  the  wound, 
and  causes  free  discharge.  Hence  the  necessity  for  drainage. 
For  this  purpose  red  rubber  tubes,  with  fenestras  cut  in  them, 
are  employed ;  and  to  keep  them  from  slipping  carbolised  silk 
threads  are  attached  to  their  external  orifices.  These  are  kept 
ready  for  use  in  i  in  20  solution.  The  wound  having  been 
closed  is  covered  by  a  piece  of  protective,  that  has  been 
dipped  in  i  in  40  solution.  Outside  this  several  layers  of 
carbolic  gauze,  wrung  out  with  i  in  40  solution,  are  applied,  and 
the  various  adjacent  inequalities,  especially  about  the  axilla,  are 
packed  with  dry  gauze.  Over  all  this  is  placed  a  large  specially 
prepared  carbolic  gauze  dressing — consisting  of  eight  superim- 

"  To  get  rid  of  the  fibrin,  &c.,  adhering  to  sponges  after  operations,  Lister 
macerates  them  for  some  days  in  water.  This  causes  putrefaction  of  the  fibrin,  after 
which  they  are  well  washed,  and  placed  in  i  in  20  solution  until  required  for  further 
use.     Sponges  are  spoilt  by  boiling. 


358 


TREATMENT    OF    ACINOUS    CANCER. 


posed  layers,  with  a  thin  sheet  of  pink  mackintosh  cloth  inter- 
posed under  the  outermost  layer.  This  must  be  long  enough 
to  reach  in  front  from  the  opposite  nipple  across  the  field  of 
operation  to  the  spine  behind,  and  wide  enough  to  extend  from 
below  the  elbow  to  above  the  top  of  the  shoulder.  At  the  level 
of  the  axilla  a  deep  vertical  notch  is  cut  in  the  upper  border  of 
the  dressing,  which  is  drawn  well  up  between  the  axilla  and  the 
arm,  and  its  anterior  and  posterior  parts  are  pinned  together 
over  the  top  of  the  shoulder.  The  whole  dressing  is  then 
secured  in  its  place  by  gauze  bandages.  The  arm  is  thus  left 
outside  the  dressing,  but  some  surgeons  so  arrange  the  latter 
that  the  whole  arm  is  included  within  it.  As  this  dressing  is 
very  apt  to  slip,  especially  at  its  edges,  these  are  secured  by 
applying  an  elastic  bandage  around  them,  and  safety  pins  are 
freely  employed  ;  but  care  must  be  taken  that  these  do  not 
perforate  the  mackintosh  sheeting. 


Fig.  47.— Jesset's  bandage  for  use  after  operations  on  the  breast. 


A  very  efficient  substitute  for  this  outside  gauze  dressing, 
and  one  that  more  readily  keeps  its  place,  is  a  similarly  shaped 
thick  layer  of  alembroth  (ammonio-mercuric  chloride)  wool, 
which,  to  distinguish  it  from  ordinary  wool,  is  stained  blue.^*^ 
Many  surgeons  also  employ  corrosive  sublimate  solutions  (i  in 
i.OOD  to  I  in  2,000),  instead  of  the  carbolic  acid  ones. 


'"  These   and    other   antiseptic   dressings  of  a   reliable  kind    are   manufactured 
and  sujjplied  by  John  Milne,  of  Lailywell,  London,  S.E. 


OPERATIVE.  359 

In  order  to  secure  perfect  rest,  the  arm — with  the  elbow 
bent  at  a  right  angle — is  bound  gently  to  the  trunk  by  a  broad 
calico  binder,  or  an  ordinary  towel.  A  pillow  should  be  placed 
under  the  elbow  to  support  it.  Jesset  has  devised  a  special 
form  of  bandage  for  use  after  these  operations,  which  is 
certainly  convenient  ^^  (fig.  47). 

The  dressing  should  be  changed  for  the  first  time  on  the 
day  after  the  operation,  for  the  next  few  days  daily,  and 
subsequently  every  two  or  three  days.  After  the  first  few 
dressings,  provided  all  is  going  on  well  and  the  drainage  tubes 
have  been  removed,  only  the  outer  dressing  need  be  changed. 

When  carbolic  acid  is  brought  very  freely  into  contact  with 
wounds  and  maintained  there,  it  is  apt  to  be  absorbed  and  to 
cause  symptoms  of  carbolic  acid  poisoning.  Hence,  subject 
to  attaining  the  object  in  view,  the  acid  should  be  brought  as 
little  as  possible  into  contact  with  the  wound  itself.  On  no 
account  should  wounds  be  forcibly  injected  with  carbolic  acid 
solutions ;  as  by  thus  forcing  the  acid  into  the  interstices  of  the 
tissues,  it  is  sure  to  be  absorbed  and  to  produce  injurious  results, 
as  in  cases  I  have  seen.  The  symptoms  of  this  accident  are 
loss  of  appetite,  nausea  and  vomiting,  with  excessive  secretion 
of  frothy  saliva.  The  urine  diminishes  in  quantity  and  becomes 
of  a  dark  olive  green  colour.  Finally,  in  severe  cases,  stertor 
with  symptoms  of  collapse  may  supervene.  With  ordinary 
care  dangerous  symptoms  hardly  ever  occur.  The  careless 
use  of  corrosive  sublimate  lotions  may  also  sometimes  cause 
symptoms  of  mercurial  poisoning. 

With  regard  to  the  choice  of  an  ancssthetic  there  is  nothing 
special  to  be  said,  except  that  the  safest  is  the  best.  The 
following  figures  show  how  it  stands  in  this  respect  with  the 
agents  in  ordinary  use  :  ^^ — 

Ether  preceded  by  gas,  12,941  consecutive  administrations 
with  I  death,  or  i  in  12,941. 

"  It  is  supplied  by  Maw,  Son  &  Thompson. 

'-  For  details  see  a  paper  by  the  author  on   "  The  Relative  Safety  of  Ether  and 
Chloroform,"  AJed.  Chronicle,  December,  1S92,  p.  150. 


360  TREATMENT    OF    ACINOUS    CANCER. 

Ether  alone,  8,391  consecutive  administrations  with  3  deaths, 
or  I  in  2,797. 

Chloroform  alone,  19,526  consecutive  administrations  with 
13  deaths,  or  i  in  1,502. 

{c)    The  Mortality  and  Causes  of  Death  after  Operation. 

Critical  inquiry  into  the  comparative  results  of  extirpation 
of  the  breast  for  cancer  shows  that  modern  operations — not- 
withstanding their  increased  severity — are  attended  by  a 
smaller  mortality  then  was  formerly  experienced,  when  far  less 
extensive  operations  were  done.  That  this  gratifying  result 
is  attributable  to  the  improved  methods  of  wound  treatment, 
which  have  come  into  use  since  the  introduction  of  Listerism, 
the  following  figures  prove  : — 

Of  167  hospital  extirpations  done  by  Velpeau^^  prior  to  1854 
the  mortality  was  19  per  cent. ;  of  305  similar  operations  done 
by  Billroth^*  prior  to  1877,  the  mortality  was  157  per  cent.  Thus 
in  these  472  7ion-antiseptic  operations  the  mortality  was  over 
17  per  cent. 

The  results  obtained  by  the  earliest  antiseptic  operations 
are  much  more  favourable  than  this. 

After  53  mammary  extirpations  by  Lister^^  (1871-80),  in 
the  majority  of  which  the  axilla  was  also  cleared,  4  patients 
died,  or  7-5  per  cent.  After  no  similar  operations  by  Volk- 
mann^''  (1874-77),  in  75  of  which  the  axilla  also  was  cleared, 
6  died,  or  5*4  per  cent.  After  68  antiseptic  extirpations  by 
Billroth^^  (1877-79),  ^^  many  of  which  the  axilla  also  was 
cleared,  4  died,  or  5'8  per  cent.  Thus  in  these  231  strictly 
antiseptic  breast  extirpations  the  mortality  was  only  6  per  cent. 

The  causes  of  deatJi  in  the   14  fatal  cases  were  as  follows  : 


'^  "Traite  des  Maladies  du  Sein,"  p.  151,  Paris,  1854. 

^^  Deutsche  Chirurgte,  Lief  xli.,  S.  155. 

•*  W.  Cheyne,  "Antiseptic  Surgery,"  1882,  pp.  373  and  382. 

""  Ibid.,  p.  388. 

"  Op.  cil.,  S.  155. 


OPERATIVE.  361 

Septicaemia  in  4 ;  erysipelas,  3  ;  shock,  3  ;  exhaustion,  2 ; 
haemorrhage,  i  ;  and  anthrax,  i. 

Recent  operators  have  had  still  better  results,  for  Gross' 
latest  mortality  is  only  37  per  cent.;  Gussenbauer's  2'8  ;  and 
Kiister's,  2"5.  Referring  to  such  progressively  favourable  re- 
sults Billroth  says  :  "  I  should  not  be  surprised  if  an  experi- 
enced operator  were  to  succeed  in  doing  100  consecutive 
extirpations  with  but  a  single  death." 

The  superiority  of  strict  Listerism  over  other  less  carefully 
devised  antiseptic  methods,  is  shown  by  the  following  data ; 
which  I  have  compiled  from  the  registrar's  reports  of  four  large 
metropolitan  hospitals. 

At  the  Middlesex  Hospital  during  the  years  1882-89  the 
breast  was  extirpated  100  times  for  primary  cancer,  with  10 
deaths.  At  St.  Bartholomew's  Hospital  during  the  years 
1886-90,  157  similar  extirpations  were  done,  with  15  deaths, 
or  9'5  per  cent.  At  University  College  Hospital  during  the 
years  1884-89,  94  extirpations  were  done,  with  9  deaths,  or 
9'5  per  cent.  At  St.  Thomas'  Hospital  during  the  years 
1886-90,  138  operations  were  done,  with  12  deaths,  or  87 
per  cent. 

Thus  at  these  four  hospitals  489  mammary  extirpations 
were  performed  for  cancer,  with  46  deaths,  being  a  mortality  of 
9"4  per  cent.  In  nearly  all  these  cases  some  form  of  antiseptic 
treatment  was  employed,  other  than  strict  Listerism.  The 
figures  show  the  marked  superiority  of  the  results  thus  obtained 
over  those  of  pre-antiseptic  methods ;  and  at  the  same  time 
they  demonstrate  the  superiority  of  Listerism  over  other  forms 
of  antiseptic  treatment. 

Butlin^^  is  averse  to  clearing  the  axilla  in  every  case  of 
mammary  cancer  destined  for  operation  because  of  the  greater 
mortality  thus  entailed,  which,  he  says,  is  much  more  than 
twice  as  great  as  when  the  axilla  is  not  opened.  I  think  he 
has  over-estimated   the  danger  of  this  proceeding,   for  of  the 

"*  "  Operative  Surgery  of  Malignant  Disease,"  1887,  p.  371. 


362        TREATMENT  OF  ACINOUS  CANCER. 

above  489  hospital  operations,  in  332  the  axilla  was  cleared  as 
well,  with  ^6  deaths,  being  a  mortality  of  I0"8  per  cent. ;  while 
of  the  other  157  cases  operated  upon — in  which  the  diseased 
breast  alone  was  removed — 10  died,  or  &;^  per  cent. 

An  analysis  of  the  causes  of  death  in  the  above  46  fatal  cases 
gives  the  following  results:  Septicaemia,  14  cases;  erysipelas, 
9  ;  pyaemia,  6 ;  pleurisy,  2  ;  pneumonia,  2  ;  bronchitis,  2  ;  shock, 
2;  and  I  each  as  follows:  traumatic  delirium,  syncope,  sup- 
puration in  the  anterior  mediastinum,  secondary  haemorrhage, 
acute  recurrence,  peritonitis  (perforation),  exhaustion,  mania 
and  renal  disease.  Thus,  of  these  46  deaths  29,  or  63  per  cent, 
were  indubitably  due  to  septic  disease.  In  most  of  the  above 
cases  the  disease  began  as  erysipelas. 

Velpeau^'*  relates  that  after  his  235  breast  extirpations  for 
cancer  54  patients  were  subsequently  attacked  by  erysipelas,  or 
23  per  cent. ;  whereas  after  395  of  the  above  hospital  operations 
only  40  were  subsequently  thus  attacked,  or  10  per  cent.  This 
shows  that  the  liability  to  septic  disease  has  been  much  dimi- 
nished by  modern  methods.  The  supervention  of  erysipelas  after 
mammary  extirpation  is  an  exceedingly  grave  complication,  for 
of  40  cases  thus  attacked  I  have  found  that  20  ended  fatally. 

It  will  be  gathered  from  the  foregoing  that  although  septic 
diseases  have  been  abated,  they  have  as  yet  by  no  means  been 
abolished. 

As  might  be  expected  from  their  comparative  triviality, 
operations  for  recurrent  cancer  are  attended  with  but  a  slight 
mortality.  Of  96  such  operations  under  my  observation  there 
was  only  a  single  death,  which  was  due  to  erysipelas,  followed 
by  septicaemia. 

Among  the  rarer  complications  that  occasionally  follow 
extirpation  of  the  breast  for  cancer,  mention  must  be  made  of 
tetanus.     The  two  following  cases  are  typical  examples  : — 

Case  I. — The  patient  was  a  lady  from  whom  Butlin"-"  had  removed  the 
breast  and  cleared  out  the  axilla.     By  the  third  day  the  temperature  had 


"•  Op.  cit.,  p.  652. 

*'  "  The  Operative  vSurj^ery  of  Malij^nanl  Disease,"  1889,  p.  370. 


OPERATIVE.  363 

fallen  to  normal.  Subsequently  all  went  well  for  nearly  a  week.  At  the 
end  of  this  time  the  wound  was  quite  healed,  except  where  a  small  drainage 
tube  had  been  inserted  into  the  axilla,  whence  a  few  drops  of  clear  fluid  still 
oozed.  On  the  eleventh  day  after  the  operation  the  patient  was  allowed  to 
get  up.  Next  day  she  presented  slight  symptoms  of  tetanus,  which  soon 
became  acute,  and  she  died  thus  four  days  later. 

Case  II. — Pritchard,  of  Clifton,-'  reports  that  after  amputation  of  a  can- 
cerous breast  the  wound  healed  quickly  by  first  intention,  and  there  was 
promise  of  speedy  convalescence,  when  one  day  the  patient  complained  of 
having  taken  cold,  and  of  pain  in  her  face.  Next  day  the  muscles  of  the  face 
were  stiff  and  hard,  and  there  was  unmistakable  "  risus  sardonicus"  and 
pain  in  the  abdominal  muscles.  These  symptoms  developed  rapidly  into 
tetanus  of  the  most  violent  kind,  with  opisthotonos,  and  death  soon  followed. 

It  has  occasionally  happened  after  extirpation  of  the  breast 
for  cancer,  as  after  other  operations,  that  insanity  has  super- 
vened. 

{d)  The  Question  of  Cure  by  Operation. 

Left  to  itself,  mammary  cancer  inevitably  ends  in  death. 
Volumes  would  be  necessary  merely  to  mention  the  remedies 
that  have  been  tried  for  its  cure  ;  but  in  spite  of  all  that  has 
been  done,  no  medicine  or  surgical  application  has  ever  yet 
been  discovered  capable  of  arresting  the  progress  of  the  disease. 
Hence  the  question  of  questions  is  —  Can  it  be  cured  by 
operation  ? 

The  views  of  our  predecessors  on  this  important  subject  may 
be  briefly  summarised  as  follows  : — Paget^^  says :  "  I  will  not  say 
that  such  a  thing  is  impossible,  but  it  is  so  highly  improbable 
that  a  hope  of  its  occurring  in  any  single  case  cannot  be  reason- 
ably entertained."  According  to  De  Morgan,^^  "  Entire  and 
permanent  immunity  after  operation  does  occur;  but  it  is  un- 
doubtedly rare."  Velpeau,^*  whose  clinical  experience  was 
unrivalled,  alone  seems  to  have  grasped  the  truth.  He  says : 
"  Des  observations  tirees  de  ma  proper  pratique  demontrent, 
sans  contestation  possible,  I'existence  de  guerisons  radicales  par 

-'  Bristol  Med.  Chir.  Journal,  Sept.,  188S,  p.  169. 

'■"  "  Lectures  on  Surgical  Pathology,"  vol.  ii. ,  1853,  p.  351. 

^  "  On  the  Origin  of  Cancer,"  1872. 

-*  "  Traite  dcs  Maladies  du  Sein,"  Paris,  1854,  p.  598. 


364  TREATMENT    OF    ACINOUS    CANCER. 

I'operation."  In  support  of  this  he  gives  details  of  twenty  cases 
in  which  freedom  from  recurrence  had  ranged  from  seven  to 
twenty-seven  years. 

In  their  definition  of  the  term  "  cure,"  the  older  surgeons 
were  more  exacting  than  we  are.  They  would  not  admit  its 
applicability  to  cases,  other  than  those  that  had  remained  free 
from  the  disease  for  at  least  ten  years  after  operation  ;  but  even 
this  severe  test  is  fulfilled  in  a  considerable  proportion  of  cases 
— in  nearly  1 1  per  cent,  of  those  analysed  by  Gross. 

It  is  now  generally  recognised  that  the  longer  the  period 
of  immunity  lasts,  the  rarer  recurrences  become.  By  modern 
surgeons  the  term  "  radical  cure  "  is  applied  to  cases  that  have 
remained  free  from  recurrence  for  at  least  three  years  after 
operation.  Volkmann's  law  is  now  almost  universally  accepted. 
"When,"  he  says,  "after  operation  a  whole  year  has  elapsed 
without  recurrence,  radical  cure  may  be  hoped  for ;  after  two 
years  it  is  probable ;  and  at  the  end  of  three  years  it  is  almost 
certain." 

It  has  been  clearly  proved  by  modern  statistical  investiga- 
tions, not  only  that  radical  cures  after  operation  do  occur,  but 
also  that  they  are  of  much  greater  frequency  than  has  hitherto 
been  generally  believed.  They  have  increased  pari  passtl  with 
the  thoroughness  of  operating.  Of  recent  operators,  those  who 
have  done  the  most  thorough  operations  have  obtained  the  best 
results.  Of  1,234  operated  cases  of  mammary  cancer  collected 
by  Gross,  146  (ir83  per  cent.)  resulted  in  radical  cure;  while 
Kcenig,  Kiister,  Gross,  Banks,  Estlander  and  Gussenbauer  esti- 
mate the  cures  in  their  latest  series  of  similar  operations 
respectively  at  22'5,  21*5,  21,  20^35,  20  and  167  per  cent. 

The  immense  superiority  of  these  results  over  those  formerly 
attained,  may  be  gauged  by  Alexander  Monro's  experience.^* 
Writing  about  1750,  this  distinguished  surgeon  says,  that  of 
sixty  cancers  he  had  seen  extirpated,  in  only  four  instances  had 
the  patients  remained  free  from  return  of  the  disease  for  upwards 
of  two  years. 

"'  "  Medical  Essays,"  p.  7. 


OPERATIVE.  365 

Hence  it  is  well  within  the  limit  to  expect  complete  cures 
after  thorough  operations  for  cancer  of  the  breast,  in  at  least 
15  per  cent,  of  all  cases.  There  is  therefore  fair  prospect  of 
saving  the  patient  by  operation.  No  other  mode  of  treatment 
has  yielded  anything  like  the  same  amount  of  success.  These 
results,  so  encouraging  alike  for  patient  and  surgeon,  ought  to 
be  more  widely  known  and  acted  upon  than  they  are  at 
present. 

Nunn*  found  that  one  in  13  of  his  cases  remained  free  from 
recurrence  after  operation  for  from  ten  to  twenty  years ;  and  of 
250  patients  operated  on  by  Velpeau.f  20  remained  free  from 
recurrence  for  periods  of  from  five  to  twenty-seven  years. 

(e)  Is  life  prolonged  by  operation  ? 

Considerable  discrepancies  are  apparent  in  the  results  arrived 
at  by  different  investigators,  as  to  the  duration  of  life  in  cancer 
of  the  breast.  Astley  Cooper  says,^^  "  The  progress  of  this 
complaint  is  in  some  persons  extremely  slow.  In  general, 
however,  it  destroys  life  in  about  four  years  from  its  commence- 
ment." According  to  Paget,^^  "  The  average  duration  of  life, 
from  the  patient's  first  observation  of  the  disease,  is  a  little 
more  than  four  years."  Bryant's  ^^  experience  agrees  with  this. 
Sibley 2^  found  the  duration  of  life  in  cases  operated  on  53-2 
months ;  and  in  those  not  operated  on  32-25  months.  Of 
Morrant  Baker's  ^°  84  cases,  for  the  ;^^;z -operated  the  average 
was  43  months  ;  and  .  for  the  operated  56-5  months.  Gross,^^ 
the  latest  worker  in  this  field,  gives  38*5  months  as  the  duration 
of  life  for  operated  cases  ;  arid  28'6  months  for  the  non-operated. 


*  "  Cancer  of  the  Breast,"  p.  45. 

t  Op.  cit.,  p.  598. 

-'^  "  Lectures  on  Surgery,"  1839,  p.  379. 

2'  "Lectures  on  Surgical  Pathology,"  1853,  vol.  ii.,  p.  344.  The  average 
duration  of  life  of  66  non-operated  cases  was  rather  over  48  months,  of  47  operated 
cases  the  average  duration  of  life  was  a  little  over  49  months. 

2«  "Diseases  of  the  Breast,"  1887,  p.  151. 

M  Trans.  Med.  Chir.  Socy,,  Lond.,  vol.  xlii. 

^  Med.  Chir.  Trans.,  vol.  xlv. 

3'  Internat.  Jour.  Med.  Sd.,  March,  1888. 


;66 


TREATMENT    OF    ACINOUS    CANCER. 


I  have  tabulated  all  the  fatal  cases  of  breast  cancer  that 
came  under  my  observation  at  the  Middlesex  Hospital  during 
a  period  of  six  years,  with  the  result  that  the  average  duration 
of  life — dating  from  the  time  when  the  disease  was  Jirst  noticed — 
is  6o'8  months  for  those  who  underwent  operation  ;  and  44*8 
months  for  those  in  whom  the  disease  ran  its  natural  course. 

Gross'  statistics  are  derived  from  massing  the  results  of  more 
than  a  dozen  different  surgeons,  chiefly  German.  He  has  not 
expressly  stated  that  in  all  his  cases  the  duration  of  life  is 
dated  from  the  time  when  the  disease  was  first  noticed  by  the 
patient.  It  appears  to  me,  whether  from  this  cause  or  some 
other,  that  his  figures  considerably  under-estimate  the  total 
duration  of  life  in  this  disease.  I  believe  the  experience  of 
English  surgeons  will  be  found  to  be  more  in  accord  with  my 
figures. 

In  further  illustration  of  this  subject  I  have  compiled  the 
following  tables  : — 

Table   I. 


Duration  of  life  in  periods  of 
5  months. 


6  lizliS  24  30 
■5  c  jto  to|to  |to  to 
j^  2ji2  t8  24  30I36 


Thirty    cases    in    which    the 
breast  viai  amputated'^'-    . . 

Thirty-four  cases  in  which  no 
operation  was  done 


I      3  13 
3      3!  5 


48  54 
to  to 
54,60 


66  72 
to 'to 
7278 


7890  oj   "§■£ 

to  tol^-S;^-^  g 

84'q6'  i-  §  I  o  2  E 


S  ca  1  4)  c-S 
oj  o  c  '  f^  °  " 

5  2  E   £  2  E 
Ji"  -   ^  = 


297 
1947 


6o-8 


This  shows  that  the  number  of  women  operated  upon,  who 
died  before  the  end  of  the  third  year,  was  40  per  cent. ;  whereas 
of  the  non-operated  the  number  who  died  before  this  period  was 
53  per  cent. 

Moreover,  the  average  duration  of  life  for  the  operated  cases 
was  16  months  more  than  for  the  non-operated. 

Of  the  4  cases  of  the  first  group  in  which  the  duration  of  the 
disease  exceeded   102   months,  it  lasted    1376,  1498,  159,  and 


^  The  immediate  risks  of  the  operation  are  not  here  included  ;  as  the  data  were 
derived  from  patients  who  had  survived  the  proceech'ng. 


OPERATIVE. 


367 


297  months  respectively.  Of  the  4  cases  of  the  second  group 
in  which  the  duration  of  the  disease  exceeded  102  months,  it 
lasted  ii6'6,  130,  157  and  1947  months  respectively. 


Table   II 

Showing  the  duration  of  life 
after  amputation  of  the  breast 
for  the  primary  disease. 

1 

to 
6 

6 
to 

12 

12 

to 

i8 

i8 
to 
24 

24 
to 

30 

30 
to 
36 

49 
to 
56 

56- 
to 

62 

68 
to 
74 

"  5 
S 

"  0 
6 

In  twenty-five  cases  33 

7 

I 

2 

I 

3 

2 

2 

2 

I 

I 

I 

I 

I 

In  these  25  cases  the  avei'age  duration  of  life,  after  extirpa- 
tion of  the  primary  disease,  was  40*3  months  ;  the  shortest 
duration  7  days,  the  longest  259  months. 


Table 

III. 

Showing  the  interval   between  the  first 
operation  and  the  first  obvious  recur- 
rence in  monthly  periods. 

£  s 

TS    0 

3 
to 

4 
3 

4 
to 

5 

I 

5 

to 
6 

4 

6 
to 
7 

I 

t^o 
8 

I 

8 

to 
9 

3 

9 
to 
10 

I 

II 
to 
12 

3 

12 
to 
13 

6 

15 
to 
16 

I 

17 
to 

18 

I 

23 

to 

24 

2 

25 

to 

26 

5 

33 
to 
34 

I 

36 
to 
37 

I 

44 
to 
45 

I 

0  c  rt 

S  <^  S 

a. 

Si       3 

In   forty-seven  cases  of  recurrent  breast 
cancer 

4 

8 

In  these  47  cases  the  average  interval  betweeji  the  first 
operation  and  the  first  obvious  recurrence  was  26  months,  the 
maximum  130  months,  the  minimum  2*5  months.  The  duration 
of  the  interval  between  the  first  operation  and  the  first  obvious 
recurrence  in  the  8  cases  of  from  52  months  and  upwards  was 
as  follows;  52  months  (2  cases),  58,  62,  89,  91,  124,  and  130 
months  respectively. 

I  think  the  facts  revealed  by  the  above  analyses  justify  us 
in  taking  a  more  hopeful  view  of  breast  cancer  than  is  custom- 
ary. We  must  not  forget  that  cancer  is  a  disease  less  malignant 
in  some  parts  than  in  others.  The  prognosis  is  certainly  much 
better  in  breast  cancer,  as  regards  duration  of  life,  than  it  is 
when  this  disease  affects  the  tongue  (when  the  total  duration  of 
life  amounts  to  18    months),  the   uterus  (24   months),   or   the 


'^  Those  who  died  of  the  immediate  lislvs  of  the  operation  are  here  included. 


368  TREATMENT    OF    ACINOUS    CANCER. 

rectum  (27  months).  In  this  respect  cancer  of  the  breast  is 
on  a  par  with  cancer  of  the  lower  lip,  in  which  the  average 
duration  of  life  is  607  months. 

Had  Hippocrates  been  aware  of  the  foregoing  facts,  he  would 
certainly  have  written  his  celebrated  aphorism,^^  relating  to  the 
operative  treatment  of  mammary  cancer,  very  differently, 

S     II , Caustic  Treatment. 

As  a  curative  means  the  treatment  of  mammary  cancer 
by  caustics  is  in  every  way  inferior  to  the  knife.  It  is  a  blind 
agency,  the  limits  of  whose  action  we  cannot  precisely  determine. 
Since,  however,  there  are  always  to  be  found  some  patients  with 
such  an  exaggerated  dread  of  cutting  operations,  that  they  can- 
not be  persuaded  to  submit  to  them,  it  may,  under  such  circum- 
stances, sometimes  be  desirable — in  the  absence  of  any  obvious 
implication  of  the  axillary  glands — to  destroy  the  disease  by 
caustics. 

It  would  be  superfluous  to  enumerate  the  many  various  sub- 
stances that  have  from  time  to  time  been  employed  for  this 
purpose.  One  of  the  most  efficient  is  chloride  of  sine — a  powerful 
tissue  coagulant,  which  for  use  is  made  into  a  paste  with  flour. 
It  is  a  painful  application,  but  it  has  the  advantage  of  not  being 
absorbed  and  of  being  easily  handled.  On  the  healthy  skin  this 
caustic  produces  comparatively  little  effect,  hence,  before  using 
it,  when  the  skin  is  unbroken,  the  latter  has  to  be  first  of  all 
destroyed  by  the  application  of  some  other  caustic,  such  as  nitric 
acid.  The  mode  of  preparing  the  paste  and  its  application, 
best  adapted  for  ordinary  use,  is  that  known  as  "  Fell's  process," 
of  which  the  details  are  as  follows  : — Take  of  chloride  of  zinc, 
16  oz. ;  opium  in  powder,  i^  oz.  ;  hydrochloric  acid,  6  drachms  ; 
boiling  water,  to  i  pint.  Macerate  the  opium  in  12  ounces  of 
the  boiling  water  for  twelve  hours,  add  the  acid  and  filter ;  then 
dissolve  the   chloride  of  zinc   in    the   filtered    liquid,  and    add 

•"  Apor.,  vi.,  38. 


CAUSTIC    TREATMENT.  369 

distilled  water  up  to  20  ounces.  The  paste  is  prepared  by 
adding  sufficient  wheatened  flour  to  this  fluid  to  render  it  of 
proper  consistence ;  thus  : — of  the  above  solution,  i  oz. ;  flour, 
120  grs.  Mix  and  heat  in  a  water  bath  until  of  proper  con- 
sistence. 

By  the  application  of  fuming-  nitric  acid  the  skin  over  the 
field  of  operation  is  destroyed.  This  is  effected  by  swabs  of  lint 
or  cotton  wool  mounted  on  pieces  of  wood,  or  by  the  use  of  a 
glass  rod  or  brush.  The  parts  adjacent  to  the  field  of  operation 
are  protected  from  its  action  by  being  first  smeared  over  with 
benzoated  lard.  Plenty  of  blotting  paper  and  alkaline  solution 
should  also  be  at  hand  to  dispose  of  any  accidental  excess  of 
acid  ;  and  care  should  be  taken  that  the  swabs,  &c.,  used,  are 
not  over-charged  with  the  acid.  The  application  is  painful, 
and  some  surgeons  employ  general  anaesthesia.  The  necessity 
for  this  may  be  avoided  by  painting  the  skin  of  the  part  with 
a  10  per  cent,  solution  of  hydro-chlorate  of  cocaine,  and  by 
subcutaneous  injections  of  a  few  drops  of  5  per  cent,  solution  of 
the  same  drug  at  various  points  in  the  field  of  operation.  By 
the  next  day  the  skin,  thus  treated,  will  be  found  to  be  con- 
verted into  a  hard  parchment-like  substance.  Into  this  multiple 
incisions  are  made  with  a  short  knife,  at  about  half  an  inch 
distance  from  one  another,  and  into  these,  narrow  strips  of  linen 
impregnated  with  the  paste  are  inserted.  The  part  is  then 
covered  with  dry,  loose,  carbolic  gauze,  and  over  this  a  layer  of 
alembroth  wool.  In  a  day  or  two  the  strips  of  caustic  linen 
should  be  removed,  and  if  necessary,  fresh  incisions  made,  into 
which  fresh  strips  of  caustic  linen  are  inserted,  and  so  on  until 
the  requisite  amount  of  tissues  have  been  destroyed. 

The  chief  difficulty  in  using  this  method,  is  to  know  when 
the  caustic  has  penetrated  deeply  enough.  It  not  unfrequently 
happens  that  its  action  is  much  more  extensive  than  was 
intended. 

In  a  case  under  my  observation,  when  the  slough  separated,  it  was  found 
that  not  only  the  disease,  but  also  the  entire  thickness   of  both  pectoral 
muscles   had   been  destroyed,   as    well    as    the    costal  cartilages,    and   the 
24 


370  TREATMENT    OF    ACINOUS    CANCER. 

adjacent  parts  of  the  2nd,  3rd,  4tb,  5th  and  6th  ribs,  thus  laying  bare  a  large 
extent  of  pleura  and  pericardium,  through  which  the  movements  of  the  heart 
and  lungs  were  plainly  visible.  In  this  condition  the  patient  lived  for  several 
months — apparently  not  much  the  worse  for  it — until  she  died  of  acute 
pyelitis.  At  the  necropsy  it  was  found  that  the  exposed  pleura  was  adherent 
to  the  adjacent  part  of  the  lung  ;  but  the  heart  and  pericardial  sac  were 
normal.  With  the  exception  of  a  cancerous  nodule  the  size  of  a  wal- 
nut, near  the  anterior  axillary  border,  the  disease  had  been  completely 
destroyed- 


§     II  I. Palliative  Treatment. 

It  is  desirable  for  cancer  patients  to  live  on  high  and  dry 
ground,  in  a  warm,  dry  climate,  where  there  is  plenty  of  sun- 
shine ;  and  exercise  in  the  open  air,  not  pushed  to  the  extent 
of  fatigue,  is  likely  to  be  beneficial.  Whatever  tends  to  divert 
the  patient's  attention  from  her  malady,  and  to  promote  cheer- 
fulness, is  desirable  ;  hence  the  good  effects  of  participating  in 
musical  and  other  social  entertainments.  With  regard  to  diet, 
the  chief  object  should  be  to  reduce  the  consumption  of  butcher's 
meat  to  a  minimum.  The  moderate  use  of  stimulants  is  to  be 
commended ;  of  wines,  port,  sherry  and  burgundy  are  the  most 
suitable,  and  of  spirits,  brandy  and  whisky.  Soda,  potash, 
lithia  or  seltzer  waters  may  be  freely  taken. 

I  have  found  no  drug  so  useful  in  the  treatment  of  cancer 
as  bromide  of  potassuun.  In  small  doses  it  has  a  very  soothing 
effect,  and  in  larger  ones  it  suffices  to  induce  sleep,  except  when 
there  is  acute  pain.  In  ordinary  cases  I  generally  employ  it  in 
combination  with  Fowler's  solution.  As  a  hypnotic  the  dose  is 
from  30  grains  upwards.  In  cases  attended  with  much  pain,  if 
the  bromide  fail  to  give  relief,  resort  must  be  had  to  opium  and 
its  derivatives. 

As  a  tonic  I  have  {o\xx\^  ferri  et  quinines  citras  and  quinince 
Valerianae  useful. 

As  local  applications  for  mitigating  pain,  belladonna  (equal 
parts  of  the  extract  and  glycerine)  and  stramonium  (ung.),  are 
chiefly  relied  on.  Cold  is  also  an  excellent  local  anaesthetic.  It 
is  applied   in    various   forms.     When    a    freezing    mi.xture  (two 


PALLIATIVE    TREATMENT.  37  I 

parts  of  pounded  ice  to  one  of  salt)  is  used,  the  application 
should  not  last  longer  than  five  or  ten  minutes.  By  this  time 
the  breast  will  be  frozen  through.  To  prevent  too  violent  re- 
action after  its  removal,  Leiter's  iced  water  coil  may  be  applied 
for  a  quarter  of  an  hour,  and  after  this  cold  compresses.  If 
instead  of  the  freezing  mixture  a  bladder  of  ice  is  employed,  it 
should  be  kept  on  for  at  least  an  hour. 

Hot  applications  should  be  avoided,  as  they  only  serve  to 
increase  the  congestion  that  is  always  associated  with  mammary 
cancer. 

Ulcerated  cancer  is  best  treated  by  washing  the  eroded  sur- 
face once  or  twice  daily  with  hyd.  perchol.  solution  (i  in  1,500), 
and  then  dressing  the  sore  with  carbolic  gauze  wrung  out  in 
I  in  20  carbolic  acid  solution,  and  over  this  a  pad  of  dry  gauze 
or  of  sal  alembroth  wool  of  adequate  size  and  thickness,  kept 
in  place  by  strapping.  In  this  way  even  the  foulest  ulcers  may 
soon  be  rendered  quite  free  from  smell. 

I  should  much  like,  did  time  and  space  permit,  to  give  here 
a  sketch  of  the  various  remedies  that  have  from  time  to  time 
been  employed  for  the  cure  of  cancer,  from  orchitic  fluid,  can- 
croin,  cultivations  of  the  streptococci  of  erysipelas,  &c.,  &c.,  to 
raw  lizards'  flesh  and  pounded  snails  ;  but  as  it  is,  I  must  instead 
refer  those  who  wish  to  pursue  these  studies  to  the  works  of  the 
classical  writers,  &c.,  and  for  the  latest  achievements — which  arc 
exceedingly  numerous — to  the  Index  Medicus,  and  other  such 
compilations. 


372 


CHAPTER  XIV. 
The  so-called  Villous  Duct  Cancers. 


No  chapter  in  the  history  of  mammary  neoplasms  is  more 
obscure  than  that  which  refers  to  the  so-called  villous  duct 
cancers.  This  is  strikingly  exemplified  by  the  many  designa- 
tions applied  to  them  by  different  observers.  It  may  be  worth 
while  to  reproduce  some  of  these,  since  they  doubtlessly  indicate, 
however  imperfectly,  varied  aspects  of  the  morbid  process. 

By  Brodie,^  who  first  clearly  differentiated  them,  they   are 
described  as  "  sero-cystic  tumours."     It  is  impossible  not  to  be 
struck  with  admiration  at  the  singularly  clear  and  penetrating 
insight  into  this  obscure  disease  which  this  distinguished  man 
had  attained,  and  that  without  the  microscope  and  other  modern 
aids.     Billroth^  calls  them  "  tubular  cyst  adenomas,"  Gross  "  true 
adenomas,"  Labbe  and  Coyne^'  "  epithelioma  intra-canaliculaire," 
Rindfleisch  "  glandular  cancroids,"  Cornil   and  Ranvier"*  "  car- 
cinoma villeux,"  while  others  have  given  them  such  names  as 
"  duct  papilloma,"  "  papillary  cndo-canalicular  fibroma,"  "  cystic 
adenoma,"  "  blood  cyst,"  "  epithcliomc  cylindrique,"  "  epithcliome 
dendritique,"  "  Epithcliome  kystique,"  "  villous  duct  epithelioma," 
"  haemorrhagic  carcinoma,"  "  duct  cancer,"  "  tubular  carcinoma," 
&c.     What  confusion  all  this  implies  !     Yet  there  is  no  lack  of 


'  "  Lectures  on  Pathology  and  Surgery,"  1846,  p.  137. 

-  Deutsche  Chir.,  Lief,  xli.,  S.  79. 

'  "  Traite  des  Tumeurs  Benignes  du  Sein,"  Paris,  1876,  pp.  206,  212,  and  264. 

*  "Manuel  d'llist.  Path,"  t.  iii.,  1S76,  p.    1167. 


VILLOUS    PAl'ILLOMA.  2>7 3 

facts,  the  problem  is  rather  to  set  these  in  order  and  to  interpret 
them  aright. 

To  this  end  I  think  the  first  and  most  important  step  is  the 
recognition  of  the  fact  that  under  this  term  "  villous  cancer," 
as  hitherto  commonly  employed,  at  least  two  perfectly  distinct 
kinds  of  neoplasm  are  included — viz.,  the  non-malignant  villous 
papilloma  and  the  malignant  tnbidar  cancer. 

I  will  now  proceed  to  sketch  briefly  the  salient  features  of 
each  of  these  diseases,  basing  my  remarks  upon  the  study  of 
thirty-six  cases,  several  of  which  have  come  under  my  own 
observation. 

S    I, Villous  Papilloma. 

Villous  papillomata  of  the  breast  may  be  either  single  or 
multiple.  They  may  arise  from  any  part  of  the  mammary  duct 
system,  but  hardly  ever  from   the  acini.     The  galactophorous 


Fig.  48. — Solitary  Villous  Papilloma  {Barker). 

No.  I  Section  through  centre  of  nipple  of  right  breast,  showing  dilated  ducts  and 
a  duct  papilloma  projecting  into  one  of  them,  {a)  Dilated  duel,  [b]  Papilloma, 
(c)  Skin,  {(i)  Nipple.  (<?)  Breast  tissue. — No.  2.  Vertical  section  through  the 
raspberry-like  papilloma  of  No.  i.  It  is  seen  to  be  made  up  of  four  main  lobes, 
each  of  them  divisible  into  smaller  leaflets. 

ducts    are   their   favourite    seats,  especially  the    lacteal  sinuses 
(fig.  48).      In  its  simplest  form  the  disease  presents  as  a  soft, 


374  VILLOUS    DUCT    CANCERS. 

granulated  or  shaggy,  pea-sized,  solitary  outgrowth  of  reddish 
or  purplish  colour,  connected  by  a  slender  stalk  with  the  wall  of 
the  duct  whence  it  originates,  as  in  cases  by  Barker,  Bryant, 
Billroth,  Pollard,  and  others.  When  such  a  growth  is  floated 
in  water,  its  branching,  arborescent  structure  at  once  becomes 
apparent.  Its  delicate  villosities,  which  are  often  of  extreme 
complexity,  are,  of  course,  easily  lacerated  ;  and  as  they  con- 
tain large  capillary  blood  vessels,  ecchymoses  and  haemorrhages 
frequently  result.  Their  prevalent  dark  colouration  is  ascrib- 
able  to  this,  and  it  has  often  caused  them  to  be  mistaken  for 
blood  clots,  and  even  for  melanosis.  On  careful  dissection  it  is 
easily  determined  that  the  cavity  within  which  the  papilloma  is 
contained  is  the  dilated  duct  itself,  and  the  fluid  contents  are 
derived  from  its  lining  membrane.  These  may  be  either  serous, 
mucoid,  or  pultaceous,  and  they  are  often  blood-stained  ;  they 
may  contain  epithelial  cells  in  granulo-fatty  degeneration,  cor- 
puscles of  Gluge,  leucocytes,  granular  debris,  cholesterine  scales, 
blood  corpuscles,  &c.,  as  well  as  dissolved  albumen.  These 
neoplasms  present  as  circumscribed  tumours  of  ovoid  or  conoid 
shape,  with  their  long  axes  parallel  to  the  main  ducts.  They 
are  usually  centrally  situated  beneath  the  nipple  or  areola. 
Though  connected  with  the  breast  itself,  they  seldom  adhere  to 
other  adjacent  structures.  They  cause  retraction  neither  of  the 
nipple  nor  of  the  overlying  skin  ;  but  these  parts  are  sometimes 
dragged  upon.  The  tumours  feel  firm,  elastic  or  fluctuating, 
but  they  seldom  attain  large  size,  the  majority  being  like 
filberts  or  walnuts.  Their  peripheral  villosities  occasionally 
protrude  through  the  dilated  galactophorous  ducts  at  the  sum- 
mit of  the  nipple,  where  they  form  red  granular  excrescences. 
More  common  than  the  solitary  papillomata  are  the  multiple 
ones  of  which  cases  have  been  recorded  by  Billroth,  Pollard, 
Labb^,  Morton,  and  others  (fig.  49).  These  may  be  confined  to 
the  ducts  of  several  adjacent  lobules,  or  to  those  of  an  entire 
lobe,  or  they  may  be  scattered  irregularly  throughout  the  ducts 
of  the  whole  gland.  Thus  firm,  irregular,  nodular  tumours  are 
produced,   which    often    attain    considerable   size.     On    section 


VILLOUS    PAPILLOMA. 


\7S 


numerous  small  cystic  cavities  are  noticeable,  within  which  the 
villous  growths  are  contained  ;  when  the  latter  grow  freely  they 
sometimes  cause  absorption  of  the  intervening  cyst  walls,  the 
result  being  a  softish  mass  of  coalesced  villous  growths,  which, 
on  section,  presents  a  spongoid  appearance,  its  meshes  contain- 
ing pultaceous  or  mucoid  fluid,  derived  from  the  cells  lining  the 
closely  packed  villosities.  In  these  cases  there  is  often  no 
distinct  capsule,  and  the  bulging  intra-canalicular  growths 
sometimes  seeming  to  infiltrate  the  surrounding  fibro-fatty 
structures. 


Fig.  49. — Multiple  Villous  Papilloma  [Gross). 


Microscopical  examination  of  mammary  papillomata  shows 
them  to  be  composed  of  a  slender  framework  of  fibrous  con- 
nective tissue,  lined  by  one  or  more  layers  of  columnar  or 
sub-columnar  epithelium  (figs.  51  and  52).  In  this  fibrous 
framework  very  few,  if  any,  cellular  elements  can  be  detected. 
It  serves  the  purpose  of  supporting  the  capillary  blood  vessels. 
In  some  instances  the  epithelial  investment  is  exceedingly 
thick  ;  upwards  of  twenty  layers  of  cells  have  been  counted. 
Under  these  circumstances  the  more  superficial  cells  lose  their 
columnar  form  and  undergo  granulo-fatty  changes.  Cells  simi- 
lar to  those  that  cover  the  free  surface  of  the  neoplasm  line  also 
the  wall  of  its  containing  cyst.  In  their  microscopic  appear- 
ances  such    growths    occasionally    present   some    resemblance 


Z1^ 


VILLOUS    DUCT    CANCERS. 


to  alveolar  cancer,  for  certain  sections  show  ovoid  spaces  con- 
taining epithelial  cells  surrounded  by  scanty  fibrous  stroma. 
These  cells,  however,  differ  from  the  cells  of  acinous  cancer, 
in  that  they  are  of  the  columnar  type  ;  and  instead  of  being 
irregularly  massed  within  the  alveolar  spaces,  they  are  regularly 
arranged  round  their  walls.  The  alveolar  appearance  is  pro- 
duced by  cross  sections  of  the  epithelial  lined,  interpapillary 
depressions,  between  the  closely  packed  ramifications  of  the 
neoplasm.     In  certain  cases,  when  the  villosities  are  lined  with 


Fig.  50.— Villous  Process  ok  Duct  Papilloma  under  a  low  power  {Morton).* 
(A)  Pigment,  probably  of  hemorrhagic  origin  ;    (B)  Blood  vessels. 

but  a  single  layer  of  epithelium,  a  tubular  appearance  is  thus 
produced. 

In  the  initial  stage  of  their  development  villous  growths 
present  as  simple  conical  or  forked  outgrowths  of  the  lining 
membrane  of  the  duct.  In  this  condition  such  growths  are 
occasionally  met  with  in  the  ducts  in  the  vicinity  of  the  fully 
developed  growths.  I'urthcr  proof  of  their  origin  from  this 
source  is  to  be  found  in  the  fact  that  the  cells  lining  their  free 
surfaces  are  invariably  of  the  same  columnar  type  as  those  of  the 


Mr.  Morton,  of  Clifton,  very  obligingly  lent  me  the  block  for  this  figure. 


VILLOUS    PAPILLOMA. 


177 


originating  ducts.  Labbe  and  Coyne'"^  have  recorded  a  case  of 
multiple  villous  papillomata  in  which  the  free  surfaces  of  the 
neoplasms  and  of  the  containing  cyst  walls  were  lined  through- 
out with  flattened  epithelium.  Here  the  disease  was  probably 
of  intra-acinous  origin,  This  is  the  only  case  of  the  kind  with 
which  I  am  acquainted. 


Fig.  51. — Villous  Papilloma  of  Breast  under  a  low  power  (Pollard). 

It  will  be  gathered  from  the  foregoing  description  that 
these  growths  are  of  a  perfectly  innocent  nature ;  though  often 
multiple,  they  have  no  tendency  to  local  infection,  nor  do  they 
ever  disseminate  in  the  adjacent  lymphatic  glands,  nor  in  the 
system  at  large ;  and  when  completely  removed  they  do  not 
recur.  Of  the  patients  in  my  list  one  was  known  to  be  alive  and 
well  14  years  after  operation,  and  others,  75,  7,  3^  and  3  years 
(two  cases).  In  a  few  instances  growths  of  this  kind  have  been 
found  associated  with  ordinary  fibro-adenomata. 

As  an  example  of  recurrence  probably  due  to  incomplete 
ablation  of  the  primary  disease,  the  following  case  by  Morton* 
is  of  interest. 


'  "  Traite  des  Tumeurs  Benignes  du  Sein,"  1876,  p.  163. 
*  Bristol  Med.  Chir.  Journal,  March,  1894. 


o/ 


VILLOUS    DUCT    CANCERS. 


A  woman,  aged  53,  with  an  irregularly  bossed  recurrent  tumour,  the  size 
of  a  cocoanut,  pendent  from  the  mammary  region  near  the  axilla.  Just 
above  it  was  the  scar  of  the  old  operation,  to  which  the  tumour  was  adherent. 
There  were  no  adhesions  with  the  subjacent  structures.  The  axillary  glands 
were  normal.  The  tumour  felt  firm  and  elastic.  Three  years  ago  the  breast 
was  amputated  for  a  tumour,  four  and  a-half  by  three  inches.     The  present 


Fig.  52. — Villous  papilloma  of  breast  under  a  high  power  {Billroth). 


recurrence  first  made  its  appearence  two  years  later.  After  removal  the 
recurrent  growth  measured  five  and  a-half  by  four  inches.  On  section  it  at 
first  appeared  to  be  a  soft  solid  growth,  enclosed  in  a  fibrous  capsule. 
Closer  examination  showed  that  it  was  composed  of  a  number  of  small  cysts 
containing  velvet-like  papillary  ingrowths  and  blood  clots.  There  was  no 
solid  growth  between  the  cysts.  Where  the  skin  was  adherent  there  was  no 
infiltration.  Histologically  examined  the  contents  of  one  of  the  smaller 
cysts  consisted  of  an  arborescent  mass  of  papillary  excrescences,  the  struc- 
ture of  which   is  shown  in  fig.    50.     In  the  hospital  museum  Morton  was 


VILLOUS    PAPILLOMA.  379 

fortunate    enough   to    find   the  primary  tumour,   which    upon    examination 
proved  to  be  identical  in  all  respects  with  the  recurrent  one. 

Usually  the  first  symptom  of  villous  papilloma  to  attract 
attention  is  the  presence  of  a  fluid  discharge  from  the  nipple, 
which  persists,  and  after  a  time  becomes  sanious.  Even  when 
this  is  not  the  initial  symptom  it  generally  appears  at  an  early 
date,  and  remains  throughout  a  salient  feature.  In  other  cases 
a  small  pea-sized  tumour  is  the  thing  first  noticed.  The 
presence  of  a  tumour  is,  however,  often  overlooked  by  the 
patient,  as  it  seldom  causes  pain  or  other  inconvenience.  The 
disease  progresses  slowly  and  almost  imperceptibly,  so  that  a 
surgeon  is  seldom  consulted  until  it  has  existed  for  several 
years.  Of  the  eighteen  cases  in  my  list  it  was  known  to  have 
existed  for  periods  of  twelve,  ten,  four  and  three  years  (two 
cases)  before  advice  was  sought.  Having  maintained  this  slow 
rate  of  increase  for  some  years,  these  tumours  not  unfrequently 
get  larger  rather  rapidly,  owing  to  increase  in  the  fluid  contents 
of  the  cysts.  In  two  out  of  my  eighteen  cases  there  was  history 
of  previous  injury;  in  one  the  nipple  had  been  severely  bitten 
twenty-two  years  previously  ;  in  the  other  the  disease  was  first 
noticed  four  months  after  a  blow.  The  patients  affected  are 
generally  prolific  married  women,  and  the  right  breast  is  as 
often  the  seat  of  the  disease  as  the  left.  The  average  age  at 
onset  was  43  years  ;  the  youngest  in  my  list  23,  the  oldest  55. 
The  numbers  for  each  quinquennial  period  were  as  follows  : — 


20  to  25  years 

25  „  30  ,)  • 

30  »  35  „  • 

35  ,:  40  „  . 

40  ,,  45  »  • 

45  »  50  »  • 

50  „  55  J)  ■ 


m  I  case 
I     „ 
I     » 
5  cases 

3     „ 


Villous  papillomata  therefore  develop  at  a  much  later 
period  than  fibro-adenomata — of  which  the  average  age  at 
onset  is  304  years ;  but  they  arise  somewhat  earlier  than 
cancers,  of  which  the  average  age  at  onset  is  48  years. 

The   disease  I  have  just  sketched  has  hitherto  almost  in- 


380  VILLOUS    DUCT    CANCERS. 

variably  been  confounded  with  cancer,  or  sarcoma,  and  treated 
like  these  affections  by  amputation  of  the  breast,  and  in  several 
cases  the  axillary  glands  have  been  removed  as  well.  It  is 
clearly  a  mistake  to  resort  to  such  severe  measures  when  we 
have  to  do  merely  with  a  solitary  villous  growth,  or  even  with 
several  such  growths  confined  to  a  limited  area  of  the  gland. 
In  these  cases  the  disease  should  be  excised,  together  with  the 
containing  cyst  wall.  Several  cases  illustrate  the  futility  of 
cutting  into  these  tumours,  and  of  destroying  the  overlying  skin 
by  caustics.  The  only  result  of  such  treatment  is  to  cause  them 
to  fungate  and  to  increase  rapidly.  When  the  disease  is  diffuse 
the  whole  gland  must  be  extirpated  ;  but  even  then  the  over- 
lying skin,  including  the  nipple  and  areola,  maj'  usually  be 
preserved. 

The  following  typical  cases  illustrate  the  leading  features 
of  this  disease. 

(i)''  A  recently  married  woman,  aged  24,  came  under  observation  with  a 
tumour  in  the  right  breast,  of  one  year's  duration.  It  was  the  size  of  a  hen's 
egg,  firm,  fixed,  and  lobulated.  No  mention  is  made  as  to  the  condition 
of  the  axillary  glands  ;  presumably,  therefore,  they  were  not  obviously 
diseased.  The  breast  was  amputated.  When  last  heard  of,  fourteen  years 
afterwards,  the  patient  was  in  good  health,  and  free  from  any  return  of  the 
disease.  On  examination  of  the  tumour  after  removal,  it  was  found  to  be 
blended  with  the  surrounding  glandular  substance.  On  section,  a  scanty 
fibroid  stroma  was  revealed,  studded  with  small  cysts,  varying  in  size  from 
a  pea  to  a  millet  seed.  These  contained  pultaceous,  yellowish  substance, 
which  on  microscopical  examination  proved  to  be  papillary  villous  growths, 
bathed  in  mucoid  fluid,  and  contained  within  dilated  acini.'  In  cross  sec- 
tions these  growths  presented  the  appearance  of  plexiform  glandular  tubuli, 
lined  by  two  or  more  layers  of  subcolumnar  epithelial  cells,  and  supported 
by  a  scanty  fibrous  stroma  (fig.  52).  Nowhere  did  these  structures  appear 
to  have  overpassed  the  limits  of  the  containing  cyst  wall.  The  growth  is 
designated  by  P>illroth  '"''  tubiildr  cyst-adciioina" 

{2f  A  married  lady,  aged  44,  the  mother  of  six  children,  of  whom  the 
last  was  born  fourteen  years  ago.  Four  years  before  she  came  under  obser- 
vation first  noticed,  in  the  upper  and   outer   part   of  her   right   breast,  a 


'■  Deutsche  Chirurgie.,  Lief,  xli.,  1880,  S.  79. 

'  These  so-called    "acini"  are  hjjured  as  lined  with  culumnar  ipitheliiiui  ;    and 
they  are  evidently  not  acini,  but  small  ducts. 

'  Labbe  et  Coyne,  "  Traite  des  Tumeurs  Benis^nes  du  Sein,"  1876,  p.  264. 


VILLOUS    PAPILLOMA.  38  I 

swelling  the  size  of  a  nut.  Her  attention  was  directed  to  it  by  the  super- 
vention of  pain  there.  In  the  course  of  about  two  years  it  increased  to  the 
size  of  a  hen's  egg,  and  the  pain  also  got  worse.  She  then  underwent 
caustic  treatment ;  but  in  reality  only  the  overlying  skin  and  subcutaneous 
tissues  were  thereby  destroyed.  Consequently  after  cicatrisation  of  the 
resulting  large  ulcer,  the  tumour  continued  to  increase.  Two  years  later 
she  applied  to  Labbe  on  this  account,  and  he  freely  excised  the  growth. 
When  last  heard  of,  nearly  three  and  three-quarter  years  after  the  operation, 
she  was  in  good  health,  and  free  from  any  return  of  the  disease.  On 
examination  of  the  part  after  removal,  a  completely  encapsuled  tumour, 
the  size  of  a  large  egg,  was  found,  which  on  section  was  of  moist,  shiny, 
greyish-white  aspect,  and  quasi-lobular  structure.  This  lobular  appearance 
was  due  to  the  presence  of  numerous  cystic  cavities — varying  in  size  from  a 
grain  of  maize  to  an  almond — completely  filled  with  papillary  ingrowths. 
The  capsule  of  the  tumour  and  the  walls  of  the  cysts  consisted  of  very  dense 
fibrous  tissue.  The  intracystic  growths  adhered  to  the  containing  cyst  walls, 
each  by  a  narrow  pedicle,  which  could  only  be  demonstrated  after  freely 
opening  the  containing  cyst,  and  turning  out  its  contents.  The  various 
cystic  cavities  communicated  with  one  another.  Often  two  or  more  of  these 
growths  sprang  from,  the  wall  of  a  single  cyst.  The  slender  pedicle  of  each 
consisted  of  old  sclerosed  connective  tissue — without  any  obvious  cellular 
elements — as  also  did  its  main  branches  ;  but  its  more  peripheral  extensions 
contained  numerous  flattened  and  rounded  cells.  The  much  ramified  free 
surface  of  these  vegetations  was  lined  by  a  single  layer  of  cylindrical  or 
cubical  epithelium,  which  at  the  level  of  the  pedicle  was  directly  continuous 
with  the  similar  cells  lining  the  containing  cyst.  The  deep  and  narrow  de- 
pressions which  separated  the  various  divisions  and  sub-divisions  of  the 
branching  growth,  seen  in  section,  presented  appearances  that  simulated 
glandular  ails-de-sac,  for  the  cylindrical  epithelium  everywhere  lined  these 
depressions.  It  was  only  by  examining  large  sections  of  the  growths  that 
their  true  nature  could  be  determined  ;  they  were  then  seen  to  be  simply 
epithelial-lined  inter-foliaceous  depressions.  Nowhere  was  there  any  exten- 
sion of  the  growth  beyond  the  cyst  walls.  This  neoplasm  is  classed  by 
Labbe  and  Coyne  as  "  Fibrome  mtra-canaliculmre  avec  vegetatioi2S  foliacees 
intra-kystiques." 

(3)  ^  A  vigorous,  healthy  woman,  aged  49,  the  mother  of  four  children. 
She  still  menstruates  regularly.  Ten  years  ago  she  first  noticed  a  small 
tumour  in  her  right  breast,  just  external  to  the  nipple.  When  she  pressed 
the  tumour  sanious  fluid  escaped  from  the  nipple.  Two  and  a-half  years 
ago  it  began  to  increase  more  rapidly  than  formerly,  and  became  fluctuating. 
About  this  time  it  was  incised,  and  a  considerable  quantity  of  reddish  viscid 
fluid  escaped.  A  fistula  resulted  at  the  seat  of  puncture,  from  which  large 
quantities  of  sanious  fluid  have  since  discharged.  When  she  came  under 
observation  the  right  breast,  beneath  the  nipple,  was  occupied  by  a  large,  soft, 
flabby  tumour,  presenting  rounded  fluctuating  bosses  and  soft  depressions,  as 


Labbe  et  Coyne,  "  Traite  des  Tumeurs  Benignes  du  Sein,'"  1876,  p.  206. 


382  VILLOUS    DUCT    CANCERS. 

from  empty  cystic  pouches.  External  to  and  below  the  nipple  is  an 
eroded  outgrowth,  surrounding  the  orifice  of  a  fistula,  whence  blood-stained 
fluid  freely  escapes.  The  skin  is  not  invaded,  although  it  is  adherent 
to  the  structures  around  the  fistulous  orifice,  and  the  tumour  is  freely 
movable  on  the  subjacent  parts.  There  is  no  enlargement  of  the  axillary 
glands.  The  tumour  was  freely  excised.  It  was  found  to  be  easily 
enucleable,  although  rather  adherent  in  some  places.  The  bulk  of  it 
consisted  of  three  large  cystic  pouches  filled  with  dark-coloured  blood. 
The  walls  of  these  cysts  were  of  fibrous  tissue.  At  numerous  points  on 
their  inner  surface,  large,  fleshy  outgrowths  were  attached,  which  projected 
into  the  cystic  cavities.  Numerous  small  cysts,  containing  intra-cystic 
growths  and  a  little  fluid,  were  found  in  the  vicinity  of  the  large  cysts. 
The  intra-cystic  vegetations  were  formed  of  much  ramified  papillary 
outgrowths,  lined  with  cylindrical  epithelium.  In  section  these  inter- 
papillary  epithelial  spaces  often  simulated  glandular  structures.  The 
pedicle  of  each  outgrowth  and  its  main  branches  consisted  of  fibrous 
tissue.  Vertical  section  entirely  through  one  of  these  vegetations  showed  a 
mass  of  branching  papillary  structures,  disposed  after  the  manner  of  the 
cerebellar  arbor  vita.  In  the  fibrous  framework  of  the  more  recent  vegeta- 
tions vascular  loops  were  visible.  The  growth  is  described  as  "  Fibrorne 
endo-canaliculaire  papillaire. " 

(4)  A  woman,  aged  35,  who  six  years  ago  had  a  miscarriage  and  seven 
years  before  this  a  stillborn  child.  Two  years  ago  she  first  noticed  a 
tumour  the  size  of  a  nut  in  the  middle  of  her  left  breast.  This  she  attributed 
to  a  blow  there,  four  months  previously.  After  the  tumour  had  existed  for 
a  few  months  she  noticed  that  on  pressing  it  a  yellowish  fluid  escaped  from 
the  nipple.  When  she  came  under  observation  there  was  at  the  upper  and 
inner  part  of  her  left  breast  a  soft  conoid  tumour,  the  size  of  a  pigeon's  &%g, 
with  its  long  diameter  parallel  with  the  main  ducts.  It  narrowed  as  it 
approached  the  nipple,  beneath  which  its  apex  disappeared  ;  its  base  was 
directed  towards  the  periphery.  The  disposition  of  the  swelling  suggested  that 
it  might  be  due  to  a  distended  galactophorous  duct.  There  were  no  adhesions 
with  the  skin,  nor  with  any  of  the  other  adjacent  parts.  The  axillary  glands 
were  normal.  The  tumour  was  excised  by  Verneuil.  On  examination  after 
removal  there  was  found,  projecting  into  a  greatly  dilated  galactophorous  duct, 
at  2  cm.  from  the  nipple,  an  arborescent  polypoid  outgrowth,  behind  which  the 
duct  was  greatly  pouched,  and  contained  some  clear  fluid.  The  neoplasm 
was  histologically  examined  by  Nepveu,  who  described  it  as  '■'■  tm  epithelioma 
a  cellules  cylindriques,"  that  had  originated  from  the  lining  membrane  of 
a  galactophorous  duct. 

(5)  '"  A  spare  but  healthy  looking  married  lady,  aged  52,  three  years  ago 
first  noticed  serous  discharge  from  the  right  nipple,  which  became  sanious  a 
week  ago.  On  examination  the  mammas  were  found  small  and  wasted. 
Just  above  and  to  the  inner  side  of  the  base  of  the  right  nipple,  was  a  hard 
nodule  the  size  of  a  filbert,  and  another  in  the  substance  of  the  breast  close 
to  it.     Manipulation  of  these  caused  sanious  fluid  to  escape  from  the  nipple. 


"  Barker,  A.  E.,  Brit.  Med.  yottrn.,  vol.  i.,  1890,  p.  590. 


VILLOUS    PAPILLOMA.  383 

The  tumours  were  neither  painful  nor  tender.  There  was  some  induration 
and  puckering  at  the  base  of  the  nipple,  which  the  patient  ascribed  to 
an  accident  twenty-two  years  ago,  when  the  nipple  was  nearly  bitten  off 
while  suckling.  The  axillary  glands  felt  knotty.  The  breast  was  amputated, 
and  the  axillary  glands  removed. 

On  examination  of  the  specimen  it  was  seen  that  the  disease  was  due  to 
the  presence  of  a  single,  bright  red,  raspberry-like,  papillary  growth,  the  size 
of  a  pea,  which  occupied  the  interior  of  a  dilated  galactophorous  duct,  at 
about  an  inch  from  the  nipple.  Several  of  the  adjacent  ducts  were  also 
dilated,  one  of  them  to  a  marked  degree.  This  growth  was  connected  with 
the  wall  of  the  containing  duct  by  a  slender  pedicle.  Its  structui^e  was 
arborescent,  consisting  of  four  primary  divisions  spreading  from  the  parent 
stem,  each  of  which  was  divisible  into  secondary  lobes,  and  these  again  into 
tertiary  ones,  and  so  on  (fig.  48).  Histological  examination  showed  that  all 
of  these  divisions  were  of  essentially  the  same  structure  ;  they  comprised  a 
central  strand  of  fibrous  tissue — containing  very  few  nuclei — enclosing  capil- 
lary blood  vessels,  and  lined  externally  by  one  or  more  layers  of  cuboid  or 
columnar  epithelium.  Sections  through  their  main  lobes  showed  a  number 
of  ovoid  spaces  lined  for  the  most  part  by  epithelium  similar  to  that  cover- 
ing the  free  surface.  These  spaces  were  separated  from  one  another  by 
fibrous  stroma,  and  into  the  largest  of  them  papillomatous  growths  projected. 
Some  of  the  sections  were  so  broken  up  by  these  spaces  as  to  present 
quite  an  alveolar  appearance.  This  the  author  attributed  to  depressions  of 
the  surface  lining  membrane  between  approximated  villosities,  seen  in  cross 
sections.  In  the  parts  of  the  breast  subjacent  to  this  papilloma  nothing 
abnormal  could  be  discovered  either  with  the  naked  eye  or  with  the  micro- 
scope. In  answer  to  a  recent  letter  of  inquiry  Mr.  Barker  has  kindly  informed 
me  that  the  patient  is  now— four  and  a-quarter  years  after  the  operation — 
well,  and  free  from  any  return  of  the  disease ;  also  that  the  removed  axillary 
glands  were  not  affected.  The  author  is  undecided  as  to  the  precise  nature 
of  the  disease,  which  he  describes  as  a  "  so-called  duct  cancer." 

(6)"  A  woman,  aged  36,  the  mother  of  five  children.  Sixteen  months  ago 
she  had  a  miscarriage.  Eleven  months  ago  she  first  noticed  a  small  lump 
in  her  right  breast,  and  a  month  afterwards  discharge  from  the  nipple. 
When  she  came  under  observation  there  was  found,  just  beneath  the  right 
nipple,  an  elastic  tumour  the  size  of  a  hazel  nut.  On  pressing  it  sanious 
fluid  escaped  from  the  nipple  and  the  tumour  diminished  in  size.  No 
mention  is  made  as  to  the  condition  of  the  axillary  glands,  so  presumably 
they  were  not  obviously  diseased.  The  tumour  was  excised,  together  with 
some  of  the  surrounding  breast  structure.  On  examination  after  removal,  in 
the  cavity  of  a  dilated  galactophorous  duct,  there  was  found  a  red,  peduncu- 
lated, papillomatous  growth,  resembling  a  ripe  raspberry.  Several  other 
small  growths,  none  of  them  larger  than  a  pin's  head,  sprang  from  other 
parts  of  the  cyst  wall.  When  last  heard  of,  six  years  later,'-  the  patient  was 
well  and  free  from  any  return  of  the  disease.  The  growth  is  classed  by  the 
author  as  a  "villous  carcinoma." 

"  Bowlby,  A.,  St.  Bart.h  Hosp.  Ref>.,  vol.  xxiv.,  p    263.     Case  i. 
'^  Lancet,  vol.  i.,  1893,  p.   1371. 


384  VILLOUS    DUCT    CANCERS. 

(7)'*  A  married  woman,  aged  50,  the  mother  of  six  children.  Twelve  years 
ago,  when  about  six  months  pregnant  with  her  last  child,  she  first  noticed 
sanious  discharge  from  her  left  nipple,  which  continued  for  three  years,  when 
a  soft,  warty  growth,  the  size  of  a  pea,  protruded  from  the  nipple.  This  was 
then  ligatured  and  cut  off,  but  it  soon  grew  again.  It  was  then  burnt  off,  but 
soon  returned.  Three  and  a-half  years  ago  it  was  repeatedly  destroyed 
with  caustics,  but  each  time  it  grew  again.  When  the  patient  first  came 
under  observation,  about  two  and  a-half  years  ago,  there  was  a  hard  lump 
in  the  breast  beneath  the  nipple,  which  extended  outwards  for  about  two 
inches.  The  axillary  glands  were  not  obviously  affected.  Eight  months 
ago  the  breast  was  amputated,  without  opening  the  axilla.  Examination  of 
the  part  after  removal  revealed  a  very  friable  growth  of  dark  red  colour, 
enclosed  in  a  distinct  fibrous  capsule.  Histological  e.xamination  showed 
closely  packed  tubules  separated  from  one  another  by  scanty  fibrous  tissue. 
These  tubular  spaces  were  lined  with  two  or  three  layers  of  cubical  epithelial 
cells,  some  of  which  contained  secondary  papillary  growths  (fig.  51).  This 
appearance  seemed  to  be  due  to  cross  sections  of  closely  appressed  arbores- 
cent papillary  structures,  of  which  the  bulk  of  the  growth  was  composed.  A 
smaller  portion  of  the  growth  was  of  more  solid  structure,  and  under  the 
microscope  the  fibrous  stroma  was  much  more  abundant  here  than  else- 
where.    The  growth  is  described  as  a  "  duct  papilloDiaP 

The  Hunterian  Museum"  contains  numerous  specimens  of  growths  of 
this  kind,  although  details  are  generally  wanting. 


S    II. Tubular  Cancer. 

As  previously  mentioned,  the  term  "tubular  cancer"  is 
applied  by  me  to  certain  cancers,  originating  from  the  mammary 
ducts,  that  histologically  are  very  duct-like  in  appearance.  They 
are  also  called  by  some  "  duct  cancers."  Cysts  and  intra-cystic 
growths,  seldom  found  in  association  with  acinous  (scirrhous) 
cancer,^'^  frequently  arise  in  connection  with  the  tubular  variety. 

The  concurrent  testimony  of  recent  observers  is  against 
Cornil  and  Ranvier's  statement,  that  villous  cancer  is  merely 
a  form  of  scirrhus  accompanied  by  intra-cystic  villous  growths. 
This    form  of  breast  cancer  is  undoubtedly  a  distinct  variety. 


"  Pollard,  B.,  Trans.  Path.  Soc,  Lone/.,  vol.  xxxvii.,  1886,  p.  483. 

'^  Nos.  280  to  290,  also  4757  to  4769,  t/.v.  Path.  Catalogue,  vol.  !.,  18S2,  also 
vol.  iv. 

'"'  In  very  exceptional  cases  villous  papilloma  and  acinous  cancer  may  coexist 
as  independent  growths  in  the  same  mamma.  See  Bowlby's  paper  (No.  2),  St.  Bart.'s 
Hosp.  Reports,  xxiv. ,  1888,  p.  265;  and  Hutchinson's  Archives  of  Surgery,  vol.  ii., 
No.  6,  Oct.,  1890,  plate  xxv.,  fig  2. 


TUBULAR  CANCER. 


385 


Histologically  it  is  characterised  by  the  presence  of  elongated, 
inter-communicating,  cellular  processes,  growing  into  the  sur- 
rounding connective  tissue  (figs.  53  and  54).  These  processes 
have  the  form  either  of  hollow  tubes  lined  with  one  or  several 


Fig.    53.— Tubular    Cancer    of    the    Breast    (hollow    form)    in 
longitudinal    section. 

(a)  Dilated  duct  giving  off  nine  prolongations  in  the  form  of  tubes  lined  by  columnar 
epithelium,  which  anastomose  with  one  another  and  with  similar]offshoots  from  other 
ducts.     (^)  Intertubular  connective  tissue  scanty.      X  100,     (Gross.) 

layers  of  columnar  epithelium  ;   or  of  solid  cellular   cylinders 
of  which  at  least  the  peripheral  cells  are  of  the  columnar  type. 
25 


386 


VILLOUS    DUCT    CANCERS. 


The  appearances  seen  in  cross  sections  are  well  shown  in 
figs.  55,  56  and  57.  In  connection  with  these  structures, 
numerous  small  cysts  frequently  arise,  through  granulo-fatty 
disintegration  of  their  cells ;  and  within  the  cysts  papillary 
growths  often  spring  up.  From  the  columnar  type  of  their 
cells,  and  from  the  tubular  form  assumed  by  the  in-growths, 
it  may  be  inferred  that  the  neoplasms  originate  from  the 
mammary  ducts.  Growths  of  this  kind  generally  present  as 
hard,  nodulated,  irregular  tumours,  which  are  usually  circum- 


Fig.    54.  —  Tubular   Cancer   of   Breast   (solid    form)   in   longitudinal   section 
(Lalibe  and  Coyne). 


scribed,  and  often  more  or  less  completely  encapsuled.  They 
vary  in  size  from  a  hazel  nut  to  a  newly  born  child's  head, 
and  commonly  they  are  as  large  as  a  hen's  egg.  They  are 
generally  mobile,  and  very  seldom  do  they  cause  retraction  of 
the  nipple,  or  of  the  overlying  skin.  On  section  we  find  them 
composed  of  firm,  whitish — or,  in  places,  pale  pinkish — solid 
substance,  formed  by  the  ingrowing  epithelial  processes,  with 
here  and   there  yellowish  areas  out  of  which  pultaceous  sub- 


TUBULAR    CANCER. 


587 


Stance — consisting  of  epithelial  cells  in  granulo-fatty  degenera- 
tion— may  be  squeezed.  Embedded  in  this  solid  substance  are 
numerous  minute  cysts.  Sometimes  the  latter  are  so  numerous 
as  to  convert  the  tumour  into  soft  reticular  substance.  These 
cystSj  some  of  which  occasionally  attain  rather  large  size,  contain 
mucoid  or  pultaceous  fluid,  and  not  unfrequently  intra-cystic 
papillary  growths.  In  this  connection  ecchymoses  and  haemor- 
rhages may  arise. 

Their  clinical  history  is  a  matter  of  great  interest.    The  chief 


Fig.  55. — Tubular  Cancer  of  Breast  (hollow  form)  in  tranverse  section,  under  a 
low  power  {.Bryant). 

points  are  as  follows  : — They  occasionally  disseminate  in  the 
adjacent  structures.  In  a  case  recorded  by  Shattock  ^^  nodules 
of  this  kind  were  found  adherent  to  the  two  upper  ribs  in  a 
woman  aged  60,  who  died  a  few  weeks  after  amputation  of 
the  breast  for  the  primary  disease.  They  have  been  found 
frequently  to  recur  locally  after  removal.     This   is  known   to 


'«  Trans,  Path,  Soc.  Land,,  li 


p.  324. 


3o5  VILLOUS    DUCT    CANCERS. 

have  happened  in  eight  out  of  the  eighteen  cases  in   my  list. 
The  most  striking  of  these  is  Butlin's.^^ 

His  patient  was  a  married  woman,  aged  64,  the  mother  of  several 
children.  Six  months  before  coming  under  treatment  she  first  noticed  a 
lump  the  size  of  a  hazel  nut  in  her  left  breast.  When  seen  she  had  a 
tumour  the  size  of  a  bantam's  egg,  below  and  external  to  the  left  nipple. 
It  was  firm,  irregular,  and  not  adherent  to  the  overlying  skin,  neither  did 
it  cause  retraction  of  the  nipple.  The  axillary  glands  were  normal.  The 
breast  was  extirpated,  together  with  the  tumour,  which  was  circumscribed 
and  invested  with  a  thin  capsule.  It  was  of  brownish-black  colour  and 
friable  consistence.     Two  years  later  she  returned  with  a  recurrent  tumour. 


Fig.  56. — Tubular  Cancer  (hollow  form),  in  transverse  section,  under  a  high 
power  {Formad). 

the  size  of  a  walnut,  at  the  axillary  end  of  the  scar.  It  was  freely  excised, 
and  presented  the  same  appearance  as  the  primary  disease.  One  year  and 
a-half  later  she  came  under  observation  again,  with  several  recurrent  nodules 
in  the  same  situation.  Tliey  were  of  a  year's  growth.  These  vvere  freely 
excised,  together  with  the  surrounding  tissues.  They  presented  the  same 
circumscribed  outline  and  brownish-black  colour  as  the  former  tumours. 
Two  years  and  nine  months  later  two   fresh  recurrent  tumours,  of  some 


Trans,  Path.  Soc,  vol.  xxxviii.,  p.  343. 


TUBULAR    CANCER.  389 

months'  duration,  were  excised  from  beneath  the  old  scar.  Their  structure 
precisely  resembled  that  of  their  predecessors.  The  axillary  glands  were 
never  affected,  nor  was  there  any  sign  of  dissemination  of  the  disease  in 
any  part  of  the  body.     The  general  health  remained  unimpaired.'^ 

The  adjacent  axillary  lymph  glands  are  occasionally  infected 
by  these  neoplasms.  This  occurred  in  five  out  of  my  eighteen 
cases.     Godlee's  is  a  typical  instance.^^ 

His  patient  was  a  childless  widow,  aged  63,  who  when  first  seen  had  a 
mammary  tumour  of  four  months'  duration.  It  was  destroyed  by  caustic. 
Three  or  four  months  later  it  recurred  in  the  scar.  A  year  later  a  small 
lump  was  first  noticed  in  the  axilla,  which  in  the  course  of  another  year  had 
grown  into  a  hard  rounded  tumour  two  inches  in  diameter,  and  the  over- 
lying skin  was  adherent  and  red.  The  breast  was  amputated,  and  the 
axillary  tumour  was  dissected  out.  On  dissection,  the  mammary  tumour 
was  found  to  be  enclosed  in  a  dense  fibrous  capsule,  which  contained  a 
considerable  quantity  of  solid  dark  brown  substance,  like  modified  blood- 
clot,  and  about  two  drachms  of  dark  treacle-like  blood.  The  axillary  tumour 
was  of  similar  nature,  only  it  contained  less  blood.  It  was  described  as 
"  an  anomalous  form  of  blood  cyst."  On  placing  the  tumour  in  water,  it 
was  seen  to  consist  of  a  number  of  tortuous  processes.  After  hardening 
it  was  very  friable,  and  difficult  to  cut  in  sections,  as  these  tended  to  fall  to 
powder.  On  microscopical  examination,  there  was  revealed  a  scanty 
fibrillar  tissue  uniting  together  a  number  of  tubules,  lined  by  several  layers 
of  hexagonal  epithelium. 

To  account  for  the  comparative  rarity  of  lymph  gland  dis- 
semination, Labbe  and  Coyne  have  pointed  out  that  between  the 
proliferating  epithelial  zone  and  the  nearest  lymphatic  lacunse, 
a  barrier  of  thick  fibrous  tissue  exists  (fig.  57),  which  must  be 
overcome  before  the  cancer  cells  can  gain  entrance  into  the 
lymphatics.  The  slowness  with  which  this  is  effected  indi- 
cates, I  take  it,  rather  the  low  degree  of  malignancy  of  the 
new  growth,  than  the  strength  of  the  intervening  barrier. 
These  neoplasms  sometimes  cause  general  systemic  dissemina- 
tion ;  my  list  comprises  two  cases  of  this  kind. 

The  following  example  came  under  my  notice  a  few  years 
ago. 

"*  In  answer  to  a  letter  of  inquiry,  Mr.  Butlin  has  kindly  informed  me  that  he 
last  saw  this  patient  in  June,  1889,  two  years  and  a-half  after  the  last  operation. 
"  She  then  had  a  small  dark  tumour  below  the  scar,  towards  the  axilla,  and  one  or 
two  hard  enlarged  glands  in  the  axilla." 

'"   Trans.  Path.  Soc.  Loud.,  vol.  xxvii.,  1S76. 


390 


VILLOUS    DUCT    CANCERS. 


A  healthy-looking  multipara,  aged  45,  thirteen  months  ago  first  noticed 
a  lump,  the  size  of  a  hazel  nut,  in  her  left  breast.  No  history  of  any 
previous  injury  or  disease  of  the  part.  On  examination  I  found  an  ovoid 
tumour,  the  size  of  a  turkey's  egg,  embedded  in  the  upper  and  outer  part 
of  her  large  breast.  The  overlying  skin  was  adherent,  and  perforated  by 
several  sinuses.  The  tumour  was  also  adherent  to  the  subjacent  structures. 
It  was  of  elastic  consistence.  No  enlargement  of  the  axillary  glands. 
Amputation  of  the  breast  and  clearance  of  the  axilla.  Erysipelas  supervened 
on  the  seventh  day  after  operation,  and  soon  afterwards  acute  left  pleurisy 
with  effusion,  and  collapse  of  the  lung,  of  which  she  died  a  few  days  later. 
At    the   necropsy   the   local    disease   appeared    to   have   been    completely 


Fig.  57. — Tubular  Cancer  (solid  form)  in  Transverse  Section. 
(a)  Fatty  tissue.    (/')  Fibrous  capsule.     (1:/)  Epithelial  cylinders.    ^Labbe  and  Coyne.) 

removed  ;  but  there  was  a  cancerous  nodule  the  size  of  a  walnut  in  the 
lower  lobe  of  the  right  lung.  Histological  examination  of  the  breast 
tumour  revealed  tubular  carcinoma. 

The  first  symptom  of  tubular  cancer  usually  is  the  presence 
of  a  small  tumour  in  the  central  part  of  the  breast,  beneath  the 
nipple  or  areola.  Discharge  from  the  nipple  is  seldom  experi- 
enced. Tubular  cancers  increase  much  more  rapidly  than 
villous  papillomas  ;    in  less  than  a  year  they  commonly  attain 


TUBULAR    CANCER.  39  I 

the  size  of  a  hen's  egg.  Occasionally  they  burst  through  the 
overlying  skin,  and  fungate.  In  my  list  there  are  four  cases 
of  this  form  of  cancer  in  which  tumours  had  been  present  for 
long  periods,  viz.,  thirty-six,  eighteen,  fifteen,  and  seven  years 
respectively.  In  each  of  these  cases  a  small  tumour  had  existed 
for  most  of  the  time — whose  increase  was  almost  imperceptible 
— and  then  during  the  last  few  years  it  had  rapidly  attained 
large  size.  There  are  several  facts  about  the  history  of  these 
cases  that  make  me  think  we  here  have  to  do  with  tubular 
cancer  supervening  on  villous  papilloma  of  many  years'  stand- 
ing, of  which  I  have  previously  reported  a  typical  instance.^^ 
The  following  is  a  similar  case  by  Labbe  and  Coyne.^^ 

A  well-nourished,  healthy-looking  woman,  aged  67,  four  years  after 
her  only  confinement,  which  was  forty  years  ago,  first  noticed  a  small 
movable  tumour  in  the  inner  part  of  her  left  breast.  She  had  at  this  time 
and  for  two  years  subsequently  sero-sanious  discharge  from  the  nipple, 
which  then  ceased  spontaneously.  After  this  the  tumour  got  larger,  then 
it  remained  nearly  stationary  for  thirty-three  years.  At  the  end  of  this 
time  it  was  the  size  of  a  small  egg.  Soon  afterwards,  without  any  obvious 
cause,  it  began  to  increase  rapidly,  and  quickly  invaded  the  whole  breast. 
In  the  course  of  three  years  a  hard  nodulated  tumour,  the  size  of  a  man's 
two  fists,  had  developed.  The  nipple  was  buried  in  the  growth,  but  not 
retracted  ;  nor  was  the  overlying  skin  adherent.  Some  of  the  bosses 
fluctuated.  Nothing  is  said  about  the  condition  of  the  axillary  glands. 
The  diseased  part  was  amputated.  On  examination  after  removal,  the 
tumour  was  found  to  be  encapsuled.  In  addition  to  the  large  lobulations 
and  bosses,  its  surface  was  thickly  studded  with  small  rounded  projections. 
On  section  its  central  part  consisted  of  whitish  compact  lobular  structure, 
and  its  periphery  was  occupied  by  numerous  small  cysts  containing  papillary 
growths  and  brownish  fluid.  Microscopical  examination  of  the  solid  basis 
of  the  tumour  showed  numerous  elongated,  tortuous,  anastomosing  cylinders 
of  epithelial  cells  growing  in  scanty  fibrous  stroma.  The  peripheral  cells 
of  these  ingrowing  processes  were  regularly  arranged  and  columnar,  those 
within  were  of  irregular  shape,  and  in  various  stages  of  granulo-fatty 
degeneration  (fig.  54.). 

Tubular  cancer  supervenes  at  a  much  later  period  of  life 
than  villous  papilloma,  and  even  than  acinous  (alveolar)  cancer. 


='  Ck.  X.,  §  9,  p.  313. 

•-'  "  Traite  des  Tumeurs  Benignes  du  Sein,"  Paris,   1876,  p.  343  ;  for  the  other 
ca.ses  vide  op.  cit.,  p.  352  ;  also  Gross,  "  Amer.  Syst.  Gyn.,"  vol.  ii.,  1S88,  p.  262. 


392 


VILLOUS    DUCT    CANCERS. 


The  average  age  of  my  cases  at  the  onset  of  the  disease  was 
53-5  years  ;  the  oldest  65-5,  the  youngest  40.  The  numbers  for 
each  quinquennial  period  were  as  follows  : — 

40  to  45  years 
45  ,.  50  ,, 
50  „  55  » 
55  »  60  „ 
60  „  65  „ 
65  „  70    „ 

The  only  treatment  of  any  avail  is  free  extirpation  of  the 
affected  part,  as  for  acinous  cancer. 


„ 

3    » 

in 

2  cases 

11 

4    » 

11 

5    » 

I  case 

§    111. "  Epithelibme  Tubule." 

Under  this  heading  French  pathologists  have  described  a 
neoplasm  with  a  fibrous  stroma  in  which  are  embedded  tubular 
structures  full  of  flattoied,  denticulated,  epithelial  cells,  present- 
ing no  signs  of  epidermic  evolution,  although  they  sometimes 
disintegrate  and  give  rise  to  cysts. 

According  to  Cornil  and  Ranvier,^^  growths  of  this  kind 
are  occasionally  found  in  the  female  breast.  They  describe 
them  as  of  slow  growth,  liable  to  disseminate  in  the  glands,  and 
as  being  sometimes  recurrent  after  ablation. 

Pean-^  has  recorded  an  instance  of  a  mammary  neoplasm  answering  to 
this  description,  which  appeared  to  have  arisen  from  epithelial  elements 
connected  with  the  areola,  rather  than  from  the  mammary  parenchyma 
itself. 

In  a  similar  case  by  Oppenheimer,^''  the  patient,  aged  63,  had  in  the 
upper  and  axillary  segment  of  her  breast  a  circumscribed  tumour,  the  size 
of  a  small  tangerine  orange.  The  nipple  was  retracted,  and  the  overlying 
skin  adherent  ;  but  there  was  no  obvious  affection  of  the  axillary  lymph 
glands.     The  tumour  had  grown  very  slowly. 


*'  "Manuel  d'Hist.  Path."  t.  i.,  1869,  p.  279. 
-*  "  Le9ons  de  Clin.  Chir.,"  1892,  p.  960. 
''  Bull,  de  Soc.  Anal.,  1888,  p.  744. 


393 


CHAPTER   XV. 
Cancer  of  the  Mammary  Integument. 


One  of  the  most  remarkable  features  about  cancer  of  this 
part  of  the  breast  is  its  extreme  rarity.  Notwithstanding  the 
exposed  position  of  the  mammary  integument,  and  the  fre- 
quency with  which  it  is  attacked  by  inflammatory  and  other 
lesions,  cancers,  nevertheless,  originate  from  it  much  more  rarely 
than  from  any  other  part  of  the  organ.  Of  1307  cases  of  mam- 
mary cancer  brought  together  by  Delbet,  in  only  eleven  ("84 
per  cent.)  did  the  disease  start  in  this  connection ;  and  of  the 
numerous  cases  tabulated  by  Gross,  only  i*3i  per  cent,  were  of 
like  origin.  When  the  disease  does  spring  up  in  this  part,  it 
is  almost  invariably  the  nipple  and  areola  that  are  affected. 
Cancer  arising  from  any  other  part  of  the  mammary  integument 
is  so  exceedingly  rare  that  neither  Velpeau  nor  Billroth,  with 
their  large  clinical  experience,  ever  met  with  a  single  instance, 
and  the  number  of  such  cases  even  now  on  record  may  be 
counted  on  the  fingers  of  one  hand. 

Attention  was  first  prominently  directed  to  this  subject  by 
PagetV  well-known  essay,  "  On  Disease  of  the  Mammary  Areola 
preceding  Cancer  of  the  Mammary  Gland,"  which  was  pub- 
lished in  1874.  He  describes  the  disease  as  beginning  with  an 
eruption  on  the  nipple  and  areola,  which,  in  most  cases,  presents 
the  appearance  of  a  florid,  intensely  red,  finely  granulated,  raw 
surface,  like  that  of  acute  eczema  or  acute  balanitis.     It  yields 

'  St.  Bart.''s  Hasp.  Reps.,  vol.  x.,  p.  87. 


394  CANCER    OF    THE    MAMMARY    INTEGUMENT. 

copious,  clear  yellowish,  viscid  discharge,  and  is  accompanied  by 
ting-ling,  itching,  and  burning  sensations.  In  other  cases  the 
eruption  resembles  chronic  eczema,  with  minute  vesications, 
succeeded  by  soft,  moist,  yellowish  scabs  or  scales,  and  accom- 
panied by  viscid  exudation.  Sometimes  it  is  dry,  like  psoriasis, 
with  a  few  whitish  scabs  slowly  desquamating.  The  persons 
affected  were  middle  aged  and  elderly  women.  It  will  be 
gathered  from  this  description — so  far  as  gross  characteristics 
go — that  the  disease  in  question  exactly  resembles  certain  pre- 
viously well  recognised  affections  of  the  part  usually  denomi- 
nated eczematous.  If  the  reader  will  compare  the  account 
given  by  Velpeau^  of  these  affections — twenty  years  previously 
— he  cannot  fail  to  be  struck  with  the  almost  absolute  identity 
in  every  respect  of  these  two  clinical  sketches.  But  the  extra- 
ordinary feature  of  Paget's  cases  is,  that  after  the  cutaneous 
disease  had  existed  for  a  year  or  two,  it  was  "  very  often  " 
succeeded  by  the  formation  of  scirrhous  cancer  in  the  substance 
of  the  gland,  without  there  being  any  obvious  connection 
between  the  two  diseases.  So  frequently  was  this  sequence 
observed,  that  Paget  concluded  the  cancer  was  probably  a  con- 
sequence of  the  cutaneous  disease,  the  suggestion  being,  that  the 
latter  induced  changes  in  the  subjacent  structures,  which  made 
them  apt  to  develop  cancer.  Paget,  however,  admits  that  the 
cutaneous  disease  may  often  be  cured  without  any  ill  consequences 
ensuing;  and  this  accords  with  Velpeau's  experience,  who  cured 
many  similar  cases  with  white  precipitate  ointment.  It  seems 
certain,  from  the  rarity  with  which — as  modern  statistical 
observations  have  shown — mammary  cancer  is  preceded  by 
eczematous  disease  of  the  nipple,  that  Paget  has  greatly  over- 
estimated the  frequency  with  which  the  latter  disease  is  followed 
by  the  former. 

One  of  the  earliest  to  investigate  the  histology  of  this  affec- 
tion was  Butlin.     In  his  first  two  cases  the  areolar  disease  was 


-  *'  Traite  des  Maladies  du  Sein,"  Paris,  1854. 


CANCER    OF    THE    MAMMARY    INTEGUMENT.  395 

unaccompanied  by  cancer  of  the  gland.^  He  found  the  mucous 
layer  of  the  epidermis  much  thickened  from  hyperplasia,  the 
corium  and  adjacent  subcutaneous  tissues  infiltrated  with  small 
round  cells ;  the  galactophorous  ducts  dilated,  and  full  of 
epithelial  cells,  which  for  the  most  part  were  of  the  flattened 
instead  of  the  usual  subcolumnar,  type.  The  periductal  tissues 
were  infiltrated  with  small  round  cells.  These  conditions  ex- 
tended for  more  than  an  inch  into  the  subareolar  part  of  the 
breast.  In  his  next  two  cases  the  areolar  disease  had  been 
succeeded  by  the  formation  of  cancer.*  In  these  the  areolar, 
ductal  and  periductal  changes  were  of  the  same  nature  as  in 
the  non-cancerous  cases.  In  one  of  the  latter  he  was  able  to 
trace  these  changes  along  the  larger  ducts  to  the  smaller  ones, 
and  so  eventually  to  the  acini,  which  were  dilated  and  filled 
with  proliferating  epithelial  cells,  as  in  commencing  cancer.  It 
will  be  gathered  from  this  description  that  Butlin  regards  the 
areolar  disease  and  its  downward  extension,  as  of  non-malignant 
inflammatory  nature. 

ThinV  account  of  the  histology  of  four  specimens,  ascribes 
the  origin  of  the  disease  to  cancerous  change  in  the  epithelium 
of  the  galactophorous  ducts  near  their  orifices.  The  disease 
remains  limited  to  this  position  for  some  time,  before  extending 
over  the  surface  of  the  nipple  ;  the  areolar  affection  he  regards 
as  a  secondary  complication,  due  to  the  irritant  action  of  the 
fluid  which  escapes  from  the  cancerous  ducts. 

Duhring*^  considers  the  lesion  to  be  a  peculiar  disease  with 
a  malignant  tendency,  which  starts  as  abnormal  cell  prolifera- 
tion of  rete  Malpighii,  and  spreads  thence  by  continuity  to  the 
lining  membrane  of  the  lactiferous  ducts,  which  he  found  filled 
with  epithelial  cells.     He  describes  the  middle  and  lower  layers 


^  "  On  the  Minute  Anatomy  of  two  Breasts,  the  Areolae  of  which  had  been  the  seat 
of  long-standing  Eczema,"  Trans.  Med.  Chir.  Soc  ,  Loud.,  vol.  lix. 

^  "  On  the  Minute  Anatomy  of  two  Cases  of  Cancer  of  the  Breast  preceded  by 
Eczema  of  the  Nipple,"  Op.  ciL,  vol.  Ix. 

'"   Trans.  Med.  Chir.  Soc.  Lond.,  vol.  Ixiv. 

*  American  Jour.  Med.  Sci.,  July,  18S4. 


396  CANCER    OF    THE    MAMMARY    INTEGUMENT. 

of  the  corium  as  infiltrated  with  epithelial  cells,  arranged  in 
alveoli,  like  "  atrophic  scirrhus."  Both  of  these  latter  observers 
describe  the  areolar  disease  as  having  a  sharply-defined, 
slightly  raised,  hard,  sinuous  margin,  with  parchment-like  in- 
duration of  the  base,  so  that  the  whole,  when  seized,  feels  not 
unlike  a  penny  piece. 

From  what  has  been  stated  it  is  evident  that  the  condition 
described  by  Thin  and  Duhring  is  quite  different  from  that 
investigated  by  Paget  and  Butlin.  It  is  specially  stated  by 
Paget  that  in  all  of  his  cases  but  one,  the  cancerous  disease 
did  not  start  in  connection  with  the  mammillary  or  areolar 
lesions,  nor  was  induration  ever  observed  in  connection  with 
the  latter  affections.  Moreover,  in  nearly  all  the  cases  reported 
by  Paget  and  Butlin  the  associated  mammary  cancer  was  of 
the  ordinary  acinous  type,  whereas  in  Thin's  cases  it  was  of 
the  tubular  type.  In  one  of  Butlin's  cases''  the  areolar  disease 
was  found  to  present  the  characters  of  cutaneous  epithelioma — 
ingrowing  interpapillary  processes  with  "  nests,"  &c.  ;  and 
Paget^  speaks  of  the  lesions  in  one  of  his  cases  as  having 
assumed — after  a  time  —  the  appearance  of  rodent  ulcer. 
Numerous  other  instances  of  cutaneous  epithelioma  origi- 
nating in  this  way  have  since  been  recorded. 

It  is  evident,  therefore,  that  several  varieties  of  cancer  may 
originate  in  association  with  what  has  been  called  "  Paget's 
disease,"  for  while  some  spring  from  the  mammary  parenchyma, 
others  take  origin  from  the  ducts,  and  others  from  the  mam- 
millary or  areolar  structures.  Thus  the  variable  progress  of  the 
disease  may  be  accounted  for.**  In  the  presence  of  these  facts 
we  may  well  ask,  with  Kaposi,  if  we  have  not  here  to  do  with 
certain  obstinate  cases  of  eczema  of  the   nipple   and   areola. 


'   Trans.  Med.  Chir.  Soc.  Land.,  vol.  Ix. 

*  Op.  cit. 

"  In  some  cases  the  cancer  has  appeared  nearly  at  the  same  time  as  the  cutaneous 
disease  ;  in  others  not  until  one,  two,  three,  four,  five,  six,  or  ten  years  afterwards  ; 
and  in  others  the  cutaneous  disease  is  known  to  have  lasted  seven,  eight,  eleven, 
twelve,  and  even  twenty  years,  without  cancer  ever  having  developed. 


CANCER     OF     THE     MAMMARY     INTEGUMENT. 


397 


complicated  with  one  or  other  of  the  various  forms  of  cancer, 
rather  than  with  a  special,  mysterious,  morbid  entity. 

The  announcement  in  1889,  that  Darier^*^  had  discovered 
parasitic  protozoa-like  bodies  in  connection  with  the  epithelial 
cells  in  this  disease  marked  a  new  epoch  in  its  history ;  and  the 
affection  soon  became  the  cynosure  of  pathological  eyes,  for 
the  problem  of  the  origin  of  cancer  seemed  to  concentre  in  it. 
These  bodies  he  describes  as  amoeba-like  protoplasmic  cells, 
becoming  after  a  time  nucleated  and  encysted,  and  looking  very 


\    <*        t\      111  '  '*^'ni 

1 1  yv- 


Fig.  58. — Pseudo-parasitic  Bodies  in  connection  with  "  Facet's  Disease  " 

{Hutchinson,  jun.). 

{a)  Hyperplastic  epidermic  cells.     (3)    Coccidia-like  bodies  with  their  contained 
psorospermia  (f)  embedded  in  the  rete.       (d)  The  subjacent  cerium  with  leucocytes. 

like  psorospermia.  They  were  found  mostly  within  the  epi- 
thelial cells  of  the  affected  part,  chiefly  in  connection  with 
those  of  the  rete  Malpighii  and  of  the  lacteal  ducts.  To  their 
presence  Darier  attributed  both  the  areolar  disease  and  the 
associated  cancer.  Wickham,^^  Hutchinson,^^  Bowlby,^^  and 
others  soon  followed  in  the  same  strain. 


'"  "  Sur  une  nouvelle  forme  de  psorospermose  cutanee,  &c.,"  Compies  Reiidus  de 
la  Soc.  de  Biol.,  13  av.,  1889. 

"  Arch,  de  MM.  exp.,  No.  i,  1890,  p.  46. 

'2    Trans.  Path.  Sor.  Land.,  vol.  xli.,  1890,  p.  214. 

'•''  Trans.  Med.  Chir.  Soc.  Lond,,  1891. 


39^  CANCER    OF    THE    MAMMARY    INTEGUMENT. 

One  of  the  first  to  repudiate  Darier's  conclusions  was 
Borrel.^^  The  so-called  psorosperms  he  regarded  as  the  pro- 
ducts of  degenerative  changes  and  of  endogenous  cell  pro- 
liferation. As  to  their  etiological  significance,  he  points  out 
that  they  have  been  found  in  association  with  various  non- 
nnalignant  affections,  such  as  papillomata,  psorospermosis  fol- 
licularis  vegetans,  and  in  the  thickened  edges  of  tubercular 
ulceration,  and  that  in  typical  instances  of  Paget's  disease  they 
are  sometimes  absent.  Moreover,  as  all  attempts  at  cultivations 
and  inoculations  have  hitherto  failed,  Borrel  explicitly  denies 
the  parasitic  nature  of  these  bodies.  In  this  view  he  is  sup- 
ported by  Thin,^^  Fabre-Domergue,^^  Delepine,^''  and  others. 
It  will  thus  be  seen  that  we  here  have  over  again,  the  same 
battle  that  has  raged  so  fiercely  with  regard  to  the  origin  of 
cancer  in  general ;  and  the  conclusion  now  arrived  at  is  the 
same,  viz.,  that  the  evidence  hitherto  adduced  as  to  the  exis- 
tence of  specific  cancer  microbes  is  altogether  inconclusive. 

This  being  so,  it  would  be  a  very  grave  error  to  proceed  to 
the  extirpation  of  every  breast  affected  with  chronic  erosive 
disease  of  the  nipple  and  areola,  in  the  absence  of  distinct  signs 
of  cancer,  as  some  surgeons  have  done  ;  for,  as  previously  men- 
tioned, recent  statistical  investigations  have  shown  that  only  a 
small  minority  of  these  cases  are  ever  complicated  with  the 
outbreak  of  cancer.  Of  course,  when  there  is  evidence  of  the 
latter  disease  having  developed,  the  same  treatment  must  be 
adopted  as  for  cancer  of  the  gland.  Otherwise  the  appropriate 
treatment  is,  first  of  all  to  wash  the  diseased  part  with  an  anti- 
septic lotion,  such  as  carbolic  acid  (i  in  20),  hyd.  perchlor.  (i 
in  1,500),  or  zinc,  chloride  (gr.  xx.  ad  5J.)  and  then  to  keep 
constantly  applied,  boric    acid,  salicylic    acid,   or   ammoniated 


'*  "  Sur  la  signification  des  figures  decrites  comme  coccides  dans  les  epith^liomes," 
Arch,  de  Med.  exp.,  t.  ii.,  1890,  p.  786. 

"  Brit.  Med.  Jour.,  May  16,  1891. 

"  Sent.  MM.,  II  av.,  1891. 

"  "Cultivation  of  Psorospermia,"  Trans.  Path.  Soc.  Land.,  vol.  xlii.,  1891,  p. 
371- 


CANCER    OF    THE    MAMMARY    INTEGUMENT.  399 

mercury  ointment,  to   either  of  which  5  per  cent  of  resorcin 
may  be  advantageously  added. 

As  examples  of  cancer  originating  in  association  with  chronic 
erosive  disease  of  the  nipple  and  areola,  the  following  cases  are 
instructive  : — 

(i)  '^  A  woman,  aged  46,  who  for  four  years  had  suffered  from  chronic 
eczematous  disease  of  the  left  areola  and  the  adjacent  parts.  The  eroded 
area  was  four  inches  in  diameter,  of  pinkish  red  colour,  with  numerous 
smooth,  pale,  shining  spots  ("ilots  epidermises")  scattered  over  it.  The 
nipple  was  retracted.  A  few  months  before  the  patient  first  came  under 
observation  there  was  noticed  in  the  breast,  some  distance  below  the  eroded 
areola,  a  hard  cancerous  lump.  The  axillary  glands  soon  became  impli- 
cated, and  the  tumour  increased  in  size.  The  whole  breast  was  then  extir- 
pated, and  the  axilla  cleared.  After  hardening  in  the  usual  manner,  sections 
of  the  skin  were  made  perpendicularly  to  the  surface  and  stained  with 
hasmatoxylin,  picro-carmine,  carmine,  &c.,  and  then  examined  especially  for 
alleged  psorospermia,  numbers  of  which  were  found  (fig.  58).  The  best  way 
of  estimating  their  number  was  by  soaking  surface  scrapings  in  liquor 
potassce  for  half  an  hour,  and  then  mounting  in  Farrant's  solution.  The 
breast  tumour  was,  for  the  most  part,  of  the  usual  acinous  type  of  cancer, 
and  there  was  dissemination  of  the  disease  in  the  axillary  lymphatic  glands. 
The  coccidia  were  found  oftenest  in  the  deepest  cells  of  the  rete  Malpicrhii. 
The  opposite  breast  was  normal.  No  one  has  yet  succeeded  in  finding  a 
distinctive  stain  for  these  pseudo-parasitic  bodies. 

(2)  '^  A  married  woman,  aged  54,  the  mother  of  eight  children,  the  youngest 
of  whom  was  born  twelve  years  ago.  Fifteen  years  ago,  when  suckling  her 
seventh  child,  she  had  sore  nipples  and  her  breasts  were  inflamed.  With 
this  exception,  she  never  had  anything  the  matter  with  her  breasts  until  the 
present  disease  began,  three  years  before  she  first  came  under  observation, 
when  the  right  nipple  became  tender,  inflamed,  and  eroded,  exuding  a 
watery  discharge.  When  first  seen  she  complained  of  severe  pain  in  the 
right  breast,  which  was  eroded  for  two  inches  around  the  nipple.  The  base 
of  the  ulcer  was  smooth  and  red,  slightly  lower  than  the  surrounding  skin, 
and  there  exuded  from  it  copious  discharge,  which  stiffened  linen.  There 
was  no  family  history  of  cancer.  The  application  of  oxide  of  zinc,  &c.,  failed 
to  cure  the  disease.  Three  years  later  the  ulcerated  area  extended  for  three 
inches  round  the  nipple,  and  it  was  acutely  painful,  and  discharged  freely. 
A  few  months  previously  a  hard  mass  was  first  noticed  in  the  middle  of  the 
breast,  beneath  the  nipple,  and  soon  afterwards  the  axillary  glands  were 
noticed  to  be  enlarged.  She  was  advised  to  have  the  disease  extirpated,  but 
could  not  make  up  her  mind  to  it  until  about  four  months  later.  The  breast 
was  then  removed  and  the  axilla  cleared.     About  seven  and  a-half  months 

'"  J.  Hutchinson,  jr.,  Trans.  Path.  Soc.  Lend.,  vol.  xli.,  1890,  p.  214. 
'"  H.  O'Neill,  Brit.  Med.  Journal,  Ap.  8,  1891,  p.  846. 


400  CANCER    OF    THE    MAMMARY    INTEGUMENT. 

later  several  small,  hard  nodules  of  recurrent  cancer  were  felt  in  the  skin  of 
the  right  axilla,  just  below  the  cicatrix  ;  also  in  the  skin  over  the  external 
condyle  of  the  right  humerus.  She  complained  of  pain  in  the  hepatic  region, 
and  the  liver  felt  enlarged  and  nodulated.  The  right  supra-clavicular 
gland,  soon  afterwards  became  enlarged.  She  died  exhausted  about  six 
weeks  later.  There  was  no  necropsy.  Histological  examination  of  the  sur- 
face disease  showed  the  usual  appearances  met  with  in  such  cases,  the  small, 
round  celled  infiltration  being  particularly  abundant.  Double  contoured 
coccidia-like  bodies  in  great  numbers  were  found  in  connection  with  the 
epidermic  cells  ;  but  none  could  be  detected  in  connection  with  the  can- 
cerous disease  of  the  breast,  which  was  of  the  ordinary  acinous  type.  The 
sections  were  stained  with  Neelson's  fluid,  picro-carmine,  safranine,  and 
logwood.  In  scrapings  treated  with  liquor  potassa,  fewer  quasi-parasitic 
bodies  were  found  than  in  the  preceding  case. 

(3)  ^"  A  lady,  aged  58,  with  intractable  eczematous  affection  of  the  left 
nipple  and  a  hard  nodule  in  her  breast  ;  the  former  lesion  of  six  months' 
duration.  The  areola  was  not  involved.  The  nipple  was  abraded,  and 
covered  at  its  base  with  thick,  sticky  substance.  From  its  base  there  was 
prolonged  downwards  into  the  substance  of  the  breast  for  about  one  and  a- 
half  inches,  a  hard  cord,  which  ended  in  an  indurated  nodule,  the  size  of  a 
horse  bean.  The  overlying  skin  was  mobile,  and  free  from  puckering,  and 
the  axillary  glands  were  not  obviously  enlarged.  A  month  later  the  middle 
third  of  the  breast,  including  the  diseased  parts,  was  excised.  On  section, 
the  small  tumour  presented  a  firm,  yellowish-white,  cupped  appearance 
just  like  ordinary  scirrhus.  Twenty  months  later  the  patient  was  well,  and 
free  from  any  return  of  the  disease.  Histological  examination  showed  that 
the  horny  layer  of  the  epidermis  had  almost  completely  disappeared  from 
the  nipple ;  the  rete  was  here  much  thickened  ;  both  it  and  the  subjacent 
corium  wei'e  densely  infiltrated  with  small,  round  cells  ;  the  sebaceous 
glands  of  the  part  were  hyperplastic,  the  galactophorous  ducts  were  dis- 
tended with  epithelium  of  a  subcolumnar  type,  and  often  multi-nucleated. 
The  deeper  ductal  and  peri-ductal  structures  were  similai'ly  affected.  The 
subjacent  tumour  was  ordinary  acinous,  spheroidal-celled  cancer.  Nothing 
is  said  as  to  the  presence  of  pseudo-parasitic  bodies. 

So  exceedingly  rare  is  it  for  cancer  of  the  mammary  integu- 
ment to  arise  in  any  other  connection,  that  I  can  cite  only  the 
following  instances : — 

Czerny's-'  patient  was  53  years  old,  and  she  suffered  from  hereditary 
tuberculosis.  She  was  the  mother  of  four  healthy  children,  all  of  whom  she 
suckled.  In  February,  1885,  superficial  swelling  of  the  left  areola  was  first 
noticed,  which  in  April  began  to  ulcerate.     In  December  the  left  mamma 


G.  Barling,  Trans.  Path.  Soc.  Land,  vol  xli.,  1890,  p.  219. 
Cent.f.  Chtr.,  No.  24,  1886,  S.  28,  in  the  Supplement. 


CANCER     OF     THE     MAMMARY     INTEGUMENT,  4OI 

appeared  full,  and  the  nipple  projecting;  the  skin  of  the  areola  was  replaced 
by  a  hard,  shallow,  epitheliomatous  ulcer,  the  edges  of  which  were  hard 
and  irregular  ;  its  base,  uneven  and  hard,  secreted  a  yellowish-red  watery 
discharge.  The  subjacent  mammary  gland  was  hypertrophied,  but  not 
involved  in  the  disease.  There  was  no  obvious  infiltration  of  the  axillary 
glands,  but  several  of  those  above  the  clavicle  were  enlarged  and  hard. 
For  the  purpose  of  diagnosis  a  portion  of  the  disease  was  scraped  away 
with  a  sharp  scoop.  On  microscopical  examination  of  these  fragments  the 
disease  proved  to  be  squamous-celled  epithelioma,  which  had  probably 
originated  from  the  interpapillary  processes  of  the  rete.  The  breast  was 
amputated  shortly  afterwards,  and  the  infiltrated  lymph  glands  were  re- 
moved. The  glandular  tissue  of  the  mamma  was  found,  on  microscopical 
examination,  to  be  quite  free  from  cancerous  change;  but  the  lymphatic 
glands  were  distinctly  cancerous.  The  patient  made  a  good  recovery,  but 
she  returned  three  months  and  a-half  later  with  a  recurrent  ulcer  the  size  of 
a  florin  at  the  outer  end  of  the  scar  in  the  chest.  This  was  destroyed  with 
the  thermo-cautery.  Czerny  points  out  that  the  condition  he  has  here 
described  is  quite  different  from  that  known  as  Paget's  disease. 

Bryant  mentions  having  seen  epithelioma  of  the  areola  arise  from  a 
suppurating,  sebaceous  cyst  in  a  middle-aged  woman  ;  just  as  similar 
disease  sometimes  supervenes  in  connection  with  suppurating  "wens" 
of  the  scalp. 

On  this  subject,  Brodie  ^^  long  ago  published  the  following 
original  observations  : — 

"A  scirrhous  tumour  may  occur  in  the  nipple,  and  I  believe  that  this 
may  properly  be  distinguished  from  a  scirrhous  tumour  of  the  breast  itself, 
and  that  there  is  a  greater  chance  of  a  permanent  cure  from  an  operation, 
where  the  disease  originates  in  the  nipple  than  where  it  originates  in  the 
breast.  There  was  a  lady  who  has  had  such  a  tumour  of  the  nipple.  She 
consulted  several  surgeons  about  it,  and  as  the  disease  was  in  a  quiet  state, 
it  was  recommended  that  it  should  be  let  alone.  After  some  time  she  came 
to  London,  and  was  under  the  care  of  the  late  Mr.  Rose,  and  I  saw  her  with 
him.  The  tumour  was  still  confined  to  the  nipple,  and  had  been  going  on 
for  some  years  without  coming  to  any  harm,  but  it  was  now  making  pro- 
gress. The  result  of  the  consultation  was  that  Mr.  Rose  removed  the  breast, 
which  appeared  sound,  the  disease  being  confined  to  the  nipple  and  its 
immediate  vicinity.  She  recovered,  and  I  have  reason  to  believe  that  the 
cure  was  permanent. 

"  Another  lady  consulted  me  concerning  a  scirrhous  tumour  of  the  nipple, 
for  so  I  call  it,  as  it  was  of  stony  hardness,  and  presented  the  usual  characters 
of  that  disease.  The  tumour  was  in  a  state  of  ulceration.  She  was  a  stout, 
elderly  lady,  with  an  enormous  breast,  and  a  great  deal  of  adeps  over  it." 
In  this  case  the  disease  was  destroyed  with  chloride  of  zinc  paste  and  caustic 
potash.     She  was  free  from  any  return  three  or  four  years  after  the  operation. 


^-  "  Lectures  on  Pathology  and  Surgery,"  1846,  p.  201. 
26 


402  CANCER    OF    THE    MAMMARY    INTEGUMENT. 

In  the  same  lecture^^  Brodie  also  refers  to  some  instances  of 
disease  which  he  believes  to  have  been  cancer  of  the  'mammary 
integument  as  follows  : — 

"A  hard  tumour  sometimes  forms  on  the  surface  of  the  breast,  which  feels 
like  scirrhus,  and  on  cutting  into  it,  it  looks  like  it,  so  that  I  can  give  the 
disease  no  other  name.  It  appears  to  be  unconnected  with  the  breast,  but 
when  you  remove  it  you  find  that  it  is  attached  to  the  surface  of  the  gland 
just  at  one  narrow  corner.  I  have  removed  three  tumours  of  this  kind, 
leaving  the  breast  untouched,  except  where  I  separated  the  tumour  from  it  ; 
and  in  each  of  these  three  cases  I  learned  that  the  patient  continued  well  a 
considerable  time  afterwards.  Indeed,  I  do  not  know  that  in  any  one  of 
them  there  has  been  a  return  of  the  disease." 

In  the  Hunterian  Museum  are  two  specimens  of  epithelioma 
of  the  nipple,  but  of  neither  of  them  are  the  histological  details 
quite  satisfactory. 

(i)  No.  4,820. — Breast  with  a  discoidal,  thin-edged  excrescence  project- 
ing from  the  nipple.  It  has  in  parts  a  warty  aspect.  Beneath  this  is  a  soft 
neoplasm,  and  deeper  still  diseased  breast  tissue  and  dilated  ducts.  From 
a  sterile  married  lady,  aged  58.  The  nipple  first  became  enlarged  and 
tender  six  months  previously.  The  breast  was  amputated,  but  she  died 
with  recurrence  in  situ  subsequently. 

(2)  No.  4,821 — The  nipple  is  occupied  by  a  small  nodular  tumour,  com- 
posed of  numerous  small  papillae,  and  surrounded  at  its  base  by  a  slightly 
raised  fold  of  skin.  The  papillae  are  lined  by  squamous  epithelium  in 
various  stages  of  evolution.  The  deeper  structures  are  infiltrated  by  epi- 
thelial ingrowths.  The  patient  was  a  single  woman,  aged  25,  and  the 
disease  was  of  six  months'  duration.  It  was  excised,  but  recurred.  The 
recurrent  disease  was  treated  by  repeated  applications  of  acid  nitrate  of 
mercury,  and  at  length  it  completely  disappeared.  When  last  heard  of  five 
years  later  she  was  free  from  any  return  of  the  disease. 

A  few  instances  of  cutaneous  epithelioma  have  been  ob- 
served in  connection  with  intertrigo  of  the  thoracico-mammary 
groove.  Richet^*  and  Winiwartcr^'^  have  each  recorded  a  case 
of  this  kind.  Mayor  and  Quenu'^^  have  met  with  similar  disease 
developed  from  the  cicatrix  of  a  burn. 


^  Op.  cil.,  p.  200. 

2«  Gaz.  des  Hop.,  No.  122,  (883. 

"^  "Beitrage  z.  Statistik  der  Carcinome,"  Stuttgart,  1878. 

**  Rh.  de  Chir.,  1881,  av.  4,  p.  990. 


403 


CHAPTER  XVI. 
Cancer  of  the  Male  Breast. 


Most  treatises  on  diseases  of  the  breast  dismiss  this  subject 
in  a  few  lines.  Considering  the  large  number  of  well-recorded 
cases  now  available  for  study,  such  a  state  of  things  is  extremely 
unsatisfactory.  That  fuller  information  about  cancer  of  the 
male  breast  is  desirable,  both  on  its  own  account,  and  because  of 
the  value  of  such  knowledge  as  a  factor  in  the  solution  of  many 
problems  relating  to  cancerous  disease  in  general,  I  have  not 
the  slightest  doubt.  Therefore,  I  have  undertaken  the  present 
investigation,  which  is  based  on  the  records  of  one  hundred 
cases,  collected  from  various  sources,  and  on  information  other- 
wise derived. 

With  regard  to  the  relative  frequency  with  which  mammary 
neoplasms  originate  in  the  two  sexes,  as  I  have  previously 
mentioned  (chap,  vii.),  nearly  99  per  cent,  occur  in  females, 
and  only  about  i  per  cent,  in  males.  Similarly,  of '1,879 
mammary  cancers  only  sixteen,  or  one  in  117,  were  males.  This 
is  a  good  illustration  of  the  law  that  obsolete  structures  have 
but  little  tendency  to  take  on  cancerous  or  other  neoplastic 
action.  Of  the  twenty-five  neoplasms  of  the  male  breast  in 
my  list,  sixteen  were  cancers,  three  sarcomas,  two  myxomas, 
and  one  case  each  of  fibro-adenoma,  angioma,  lipoma,  and 
cystoma.     Of  269  similar  cases  collected  by  Schuchardt,^  244 

'  Arch.f.  klin.  Chir.,  Bd.  xxxi.,  1885,  S.  57. 


404  CANCER    OF    THE    MALE    BREAST. 

were  cancers,  three  sarcomas,  three  fibromas,  two  fibro-adenomas, 
fifteen  cysts,  one  enchondroma,  and  one  myoma. 

A  predisposing  cause  to  cancer  and  other  tumours  of  the 
male  breast  may  be,  as  Creighton  suggests,  the  undue  persist- 
ence in  certain  cases  of  an  unusual  amount  of  glandular 
parenchyn:>a,  together  with  corresponding  impulses  to  imperfect 
functional  activity. 

Cancer  of  the  male  breast,  like  that  of  the  female,  may 
originate  either  from  the  acini,  the  ducts,  or  the  integument. 
Of  my  100  cases  91  were  of  the  acinous  variety  (melanotic  two), 
six  of  the  tubular  (cylinder-celled  duct  cancers),  and  three  were 
squamous-celled  epitheliomas  (melanotic  one).  It  appears  from 
this  that  the  male  breast  is  relatively  more  liable  to  the  tubular 
variety  of  cancer  (which  originates  from  the  ducts)  than  the 
female.  This  is  only  what  one  might  have  expected  a  priori, 
because  in  the  normal  condition  of  the  male  breast  ducts  pre- 
dominate, and  acini  are  but  imperfectly  developed.  It  will  also 
be  gathered  that  cancer  of  the  mammary  integument  is  of  much 
more  frequent  occurrence  in  males  than  in  females.  This 
accords  with  the  distribution  of  integumentary  cancer  in  general, 
which  is  met  with  much  oftener  in  males  than  in  females. 
Another  fact  worth  noting,  is  the  comparatively  frequent  occur- 
rence of  melanotic  cancer  in  the  male  breast  (3  per  cent.). 
Growths  of  this  kinds  in  general,  arise  much  more  frequently  in 
connection  with  structures  of  integumentary  origin  than  with 
any  others.  In  the  male  breast  we  have  to  do  with  a  structure 
of  this  kind,  which,  having  lost  most  of  its  special  characters,  is 
in  process  of  reversion  to  the  primordial  cutaneous  condition, 
out  of  which  it  formerly  evolved.  Herein  we  may  find  an 
explanation  of  its  comparative  proneness  to  melanosis. 

Of  the  ninety-one  acinous  cancers  three  were  described  as 
"encephaloid,"  but  as  in  all  these  cases  the  histological  exami- 
nation was  wanting,  nothing  special  need  be  said  about  them. 
I  will  only  remark,  that  of  the  numerous  mammary  cancers 
examined  by  me,  I  have  never  met  with  a  single  instance  of 
encephaloid  acinous  cancer  ;   all  the  supposed  examples  of  this 


CANCER    OF    THE    MALE    BREAST. 


405 


kind,  on  histological  examination,  proved  to  be  either  carcinoma 
myxomatodes,  tubular  cancer,  sarconria,  nnyxoma,  or  villous 
papilloma. 

I  will  now  set  forth  the  results  of  an  analytical  summary  of 
the  remaining  eighty-eight  acinous  cancers,  leaving  the  others 
for  separate  treatment. 

Age. — The  earliest  age  at  which  the  disease  was  first  noticed 
(in  eighty-eight  cases)  was  20  years,  the  latest  82  years,  the 
mean  age  50  years.  In  the  subjoined  table  the  numbers  for 
each  quinquennial  period  are  given,  calculated  on  the  percentage 
basis,  and  for  comparison  I  have  appended  the  corresponding 
numbers  in  cancer  of  the  female  breast : — 


Sex. 

.0  6  S 
c  0 

2  t 
0^ 

N    0 

0  f, 
0^ 

1 
0  2 1  °  id 

„0     ^^ 

2  t 
5o 

2  t 

2  t 

2  t 
0^ 

2  i- 

vo    0 

>  >• 
0  o_ 

D    1) 

Males         

Females 

88 
500 

2 
0-6 

2 

4 

9 
6 

12        II 
14        16 

^7 
20 

15 
IS 

12 
10 

7 
9 

3 
3-2 

10 

2'2 

50 
48 

20 
22 

82 
84 

It  will  be  seen  from  this  table  that  the  average  age  at  which  the 
disease  originates  in  males  is  two  years  later  than  in  females. 
It  is  further  noticeable  that  a  relatively  large  number  of  the  male 
cases  begin  over  70.  In  most  other  respects  there  is  remarkable 
similarity  as  to  the  age  distribution  in  the  two  sexes.  Not  a 
single  case  originated  in  either  sex  under  the  age  of  20. 

Total  Duration  of  Life. — In  eighteen  fatal  cases  the  total 
duration  of  life,  dating  from  the  time  when  the  disease  was  first 
noticed,  averaged  sixty-one  months,*which  is  about  eight  months 
longer  than  the  average  duration  of  the  disease  in  the  opposite 
sex.  Of  the  above  cases,  5  had  undergone  amputation  of  the 
breast,  &c. ;  in  these  the  duration  of  life  averaged  about  124 
months,  or  20*5,  27,  117,  182,  and  273  months  each.  In  the 
other  13  cases  no  operation  had  ever  been  performed;  in  these 
the  duration  of  life  averaged  38  months,  the  shortest  period 
1 1  months,  the  longest  85  months. 

Duration  of  Life  subsequently  to  Amputation  for  the  primary 
Disease. — This  was  noted   in   6  cases,  it   averaged    nearly   60 


4o6 


CANCER  OF  THE  MALE  BREAST. 


months.  The  exact  duration  in  each  case  was  as  follows  :  26 
days,  I  month,  5,  13,  78,  and  260  months.  In  25  similar  cases 
of  the  female  breast  I  found  the  average  period  was  about  40 
months,  the  longest  259  months. 

Interval  betiveen  first  Operation  and  first  obvious  Recurrence. 
— In  14  cases  this  averaged  97  months,  the  maximum  32"5,  the 
minimum  15  months.  In  females,  according  to  my  observations, 
the  average  interval  is  26  months.  The  following  figures  further 
illustrate  this  subject : — 

in  3  cases 
„  I  case 


3  months 

and  under 

3  to 

4  months 

8  months 

10 

T  '^ 

0 

19-5 

26*0 

32-5 

Civil  state.- 

-Of   12  C 

-Of  12  cases,  7  were  married,  2  widowers,  and  3 
single.  Particulars  with  regard  to  offspring  are  given  in  3  cases : 
one  was  the  father  of  6  and  another  of  15  children,  the  other  had 
no  offspring.  In  38  cases  the  occupation  had  been  as  follows  : 
butcher,  gentleman,  and  carpenter  each  in  3  cases ;  sailor, 
compositor,  merchant,  teacher  and  clerk,  each  in  2  cases  ;  soldier, 
brass-finisher,  'bus  conductor,  piano  factory,  chimney-sweep, 
clergyman,  blacksmith,  locksmith,  publican,  labourer,  waggoner, 
hospital  attendant,  plasterer,  peasant,  bootmaker,  carrier,  coach- 
man, stone  sawyer,  and  hall  porter,  each  in  i  case. 

The  Side  affected. — Right  side  in  38  cases,  or  53  per  cent.; 
left  in  II  cases,  or  47  per  cent.  In  females  the  left  breast  is 
always  the  more  frequently  affected.  In  4  of  the  above  '^'i 
cancers  of  the  male  breast  both  breasts  were  affected  on  ad- 
mission, but  in  no  instance  were  both  breasts  primarily  affected. 
Similarly  of  151  cases  in  females,  in  7  both  breasts  were  in- 
volved on  admission. 

Seat  of  initial  Lesion. — This  was  noted  in  14  cases  ;  in  8  the 
disease  was  central,  being  situated  underneath  the  nipple  ;  in  3 
it  was  near  the  nipple  ;  in  i  below  the  nipple  and  to  its  axillary 
side ;  in  i  below  and  to  its  sternal  side  ;  and  in  i  above  the 
nipple  and  to  its  axillary  side. 


CANCER  OF  THE  MALE  BREAST.  407 

Character  of  initial  Lesion. — In  42  cases  this  was  as  follows  : 
— Small  nodule  or  lump  (varying  in  size  from  a  pea  to  a  hazel- 
nut) in  30  cases  ;  enlargement  and  induration  of  gland  in  5  ; 
redness,  soreness,  or  induration  of  nipple  or  areola  (Paget's 
disease)  in  7. 

Discharge  from  the  Nipple. — This  was  noticed  during  the 
course  of  the  disease  in  7  out  of  88  cases ;  it  was  sanious  in  4, 
puriform  in  2,  and  lactiform  in  i.  According  to  Gross,  females 
are  liable  to  similar  discharges  in  15  out  of  207  cases. 

Previous  Injury  or  Disease  of  Breast. — Of  30  cases  there  was 
a  history  of  previous  injury  or  disease  in  16,  or  53  per  cent., 
as  compared  with  43  per  cent,  in  females.  The  injuries  are 
described  as  contusions  in  10  cases,  recurrent  pressure  at  work 
in  2,  and  strain  in  2.  The  only  previous  diseases  noted  were 
two  cases  of  long-standing  eczema  of  the  nipple  and  areola. 

Previous  Health. — This  was  stated  in  13  cases.  It  had  been 
good  in  1 1  (with  no  serious  illness  since  youth  in  3),  and  bad  in 

2  cases.  The  following  previous  diseases  were  noted  as  having 
occurred  since  childhood  : — Pneumonia  and  migraine  each  in  2 
cases ;  tubercular  arthritis  of  knee,  haemorrhoids,  eczema,  ery- 
sipelas of  face,  herpes  zoster,  chancre,  gonorrhoea,  epilepsy,  and 
dyspepsia  each  in  i  case.     With  regard  to  the  patient's  habits, 

3  are  said  to  have  been  temperate  and  3  intemperate.  As  to 
syphilis,  inquiries  were  made  in  7  cases,  but  there  was  evidence 
of  this  disease  only  in  i. 

Family  History. — Of  29  cases  in  which  inquiries  were  made, 
there  was  history  of  cancer  in  7  families,  or  in  24  per  cent. 
The  relatives  thus  affected  and  the  seats  of  the  disease  may 
be  shown  as  follows  : — 

Father's  mother  (one  family)  ...     Locality  not  stated. 

Father's  sister  (one  family)   ...  ...     Breast. 

r  Neck. 
Fathers  (four  families)  <  gj.g^gj. 

\  Locality  not  stated. 


408  CANCER  OF  THE  MALE  BREAST. 

(  Tongue. 

Mothers  (three  families)         ...  ...-(Lip. 

(LocaHty  not  stated. 

Patient's  sisters  (two  families)  . . .  |  l'^^^^\[y  ^^^  stated. 

Thus  of  the  7  cases  in  which  the  seats  of  hereditary  disease 
are  stat;ed,  the  breast  was  affected  in  3.  In  3  cases  there 
was  history  of  cancer  in  more  than  a  single  relative: — (i) 
Father  died  of  cancer  of  neck,  and  mother  died  of  cancer  of 
tongue  ;  (2)  father  died  of  cancer  (locality  not  stated),  and  2  of 
patient's  sisters  (i  of  breast,  the  other  locality  not  stated)  ;  (3) 
father's  mother  and  patient's  mother  both  died  of  cancer 
(locality  not  stated). 

Duration  of  the  Disease  from  the  time  it  was  first  noticed  until 
the  patient  came  under  observation. —  In  86  primary  cases  this 
averaged  29'5  months;  in  119  primary  cancers  of  the  female 
breast  the  average  was  26"5  months.  The  following  statement 
further  illustrates  this  subject : — 


Under  6  months 

6  to  12 

)> 

12  ,,  18 

11 

18  „  24 

)5 

24  »  30 

J> 

36  „  42 

>» 

42  „  48 

)> 

48  „  54 

11 

60  „  66 

11 

78  „  84 

11 

104 

11 

n   7 

cases 

,,  IS 

,,  14 

„   7 

„  12 

„  II 

11      I 

case 

,,  10  cases 

1 

11 

)> 

11      3 

11 

11      4 

11 

In  10  recurrent  cases  the  duration  of  the  disease  when  the 
patient  first  came  under  observation  had  averaged  62  months, 
as  compared  with  75  months  in  39  cases  of  recurrent  cancer 
of  the  female  breast.  In  2  cases  the  duration  of  the  disease  had 
exceeded  102  months — viz.,  129  and  130  months  respectively. 

State  on  Admission. — Of  26  primary  cases,  20  were  well 
nourished  (obese  4,  sallow  i);  of  these,  9  were  ulcerated  and 
1 1  non-ulcerated.  The  other  6  cases  were  weak  and  emaciated 
(sallow  2)  ;  of  these,  5  were  ulcerated  and  i  non-ulcerated.     In 


CANCER  OF  THE  MALE  BREAST.  4O9 

14  of  the  above  cases  retraction  of  the  nipple  was  noted.  In  2 
cases  the  primary  disease  had  assumed  the  atrophic  form,  in  2 
cases  the  diffuse  discrete  form,  and  in  i  case  the  en  cuirasse 
form ;  in  the  others  it  presented  as  a  more  or  less  circumscribed 
mass.  Of  3  recurrent  cases,  2  were  non-ulcerated  (i  well 
nourished,  i  weak  and  emaciated)  ;  i  was  ulcerated,  the  patient 
being  weak,  emaciated,  and  sallow. 

The  Axillary  Glands,  &"€. — Of  68  primary  cases,  there  was 
obvious  enlargement  of  the  axillary  glands  in  43,  or  in  63  per 
cent.  In  2  cases  the  glands  near  the  clavicle  were  affected  as 
well ;  both  of  these  were  ulcerated.  Of  the  43  cases  in  which 
the  axillary  glands  were  affected,  26  were  non-ulcerated  and 
17  ulcerated.  Of  25  cases  in  which  there  was  no  obvious 
affection  of  the  axillary  glands,  20  were  non-ulcerated  and  5 
ulcerated.  Of  12  recurrent  cases,  there  was  obvious  enlarge- 
ment of  the  axillary  glands  in  4  (clavicular  glands  as  well 
in  I  non-ulcerated  case) ;  of  the  latter,  2  were  ulcerated  and 
2  non-ulcerated.  The  other  8  cases,  in  which  there  was  no 
glandular  affection,  were  all  non-ulcerated. 

Treatment  and  Result. — The  treatment  of  cancer  of  the 
male  breast  should  be  conducted  in  accordance  with  the  same 
principles  as  cancer  of  the  female  breast ;  free  extirpation  of 
Xhepectoralis  major  muscle  being  even  more  imperative  in  males 
than  in  females.  Of  56  amputations  of  the  breast  for  primary 
cancer  there  were  only  2  deaths — a  mortality  of  3*6  per  cent. 
In  20  of  these  cases  the  axillary  glands  were  removed  as  well ; 
the  2  fatal  cases  belong  to  this  category.  Both  of  them  died  of 
septicaemia  about  a  month  after  the  operation.  With  regard  to 
the  other  cases,  the  ultimate  result  is  stated  only  in  3  ;  in  all 
there  was  recurrence :  (i)  in  the  axilla  two  years  and  three- 
quarters  after  the  operation,  with  subsequent  invasion  of  the 
thorax  by  direct  extension  ;  (2)  in  the  chest  three  months  after 
the  operation,  and  death  twelve  months  later,  with  metastatic 
deposits  in  liver  and  bones  ;  (3)  in  the  chest  a  few  months  after 
the  operation ;  this  was  destroyed  with  caustic  several  times, 
but  it  returned  and  increased  rapidly.  The  average  period  of 
convalescence  in  8  of  the  above  cases  was  thirty  days. 


4IO  CANCER    OF    THE    MALE    BREAST. 

In  the  other  '>^6  cases  the  axillary  glands  were  not  touched. 
All  of  these  recovered.  The  average  period  of  convalescence 
in  6  cases  was  eighteen  days.  The  ultimate  result  is  men- 
tioned in  14  cases  as  follows : — One  was  well  eleven  years 
after  the  operation,  and  quite  free  from  recurrence;  another 
died  six  years  after  of  apoplexy,  without  any  recurrence.  In 
the  other  12  cases  there  was  recurrence — 'in  the  chest  in  '9, 
opposite  breast  in  2,  and  the  axilla  in  i.  In  6  of  these  the 
recurrent  disease  was  extirpated  ;  all  recovered  from  the  ope- 
ration. The  ultimate  result  was  as  follows  : — (i)  Four  months 
after  amputation  of  the  breast  for  the  primary  disease  there  was 
recurrence  in  the  opposite  breast ;  this  was  amputated.  There 
was  no  further  recurrence  in  either  chest  or  axilla  ;  but  2^ 
years  after  the  last  operation  a  recurrent  nodule  formed  in  the 
skin  of  the  hand,  which  was  successfully  excised.  (2)  At  the 
primary  operation  both  breasts  were  amputated.  There  was 
recurrence  a  year  later  in  the  left  axilla.  This  was  excised. 
The  disease  recurred  six  years  later  in  the  left  chest  and  axilla. 
Two  years  later  he  was  reported  dying  from  invasion  of  the 
thorax  by  direct  extension.  (3)  Soon  after  amputation  of  the 
left  breast  for  primary  cancer,  recurrence  was  noticed  in  the 
chest.  In  the  course  of  ten  years  it  increased  to  the  size  of  an 
orange,  and  several  discrete  hard  nodules  developed  at  the 
axillary  end  of  the  scar,  but  there  was  no  obvious  affection  of  the 
axillary  glands.  At  the  end  of  this  time  the  recurrent  disease 
was  excised.  There  was  no  subsequent  return  of  the  disease 
in  the  chest  or  axilla,  but  eleven  years  afterwards  the  patient 
died  with  cancerous  growths  in  the  liver  and  in  the  cardiac 
part  of  the  stomach,  (4)  There  was  recurrence  in  the  chest 
seven  months  after  amputation  of  the  breast  for  the  primary 
disease.  This  was  excised,  but  there  was  further  recurrence 
soon  afterwards.  (5)  The  disease  recurred  in  the  opposite 
breast  a  month  and  a-half  after  amputation  of  its  fellow  for  the 
primary  disease.  This  breast  was  also  amputated  ;  he  was  con- 
valescent ten  days  later,  (6)  Recurrence  in  the  chest  eight 
months  after  amputation  of  the  breast  for  the  primary  disease. 


CAlsfcER    OF    THE    MALE    BREAST.  4II 

Four  months    later  this  was   excised  ;    but  the  disease   subse- 
quently recurred  in  the  chest. 

Initial  Seat  of  the  Recurrent  Disease. — This  was  noted  in  14 
cases  : — In  10  the  disease  was  seated  in 'the  mammary  region. 
(No  glands  were  removed  at  the  primary  operation  in  4,  glands 
were  removed  at  the  primary  operation  in  2,  not  stated  in  4.)  In 
2  it  was  situated  in  the  opposite  breast.  (No  glands  in  either 
case  were  removed  at  the  primary  operation.)  In  2  it  occupied 
the  axillary  glands.  (At  the  primary  operation  the  glands  were 
removed  in  i,  and  not  touched  in  i.) 

Causes  of  Death. — In  18  fatal  cases  the  causes  of  death 
were  as  follows  :  asthenia,  with  metastatic  growths,  in  7  cases  ; 
invasion  of  thorax  by  direct  extension  in  6  cases,  not  stated 
in  2  cases,  septicaemia  (after  operation)  in  2  cases,  apoplexy 
(without  any  recurrence)  in  i  case. 

The  Necropsies. — Of  these  only  10  were  recorded.  There 
were  metastatic  deposits  in  7  cases,  or  in  70  per  cent.  In 
two  other  cases  the  thorax,  lungs,  &c.,  were  invaded  by 
direct  extension.  In  these  7  cases  the  metastatic  deposits 
were  situated  as  follows  :  in  the  liver  in  3  cases,  lungs  and 
pleura  (both  2,  right  i)  in  3,  and  bones  in  3  ;  kidneys  (both) 
in  I  case ;  bladder  in  i  ;  peritoneum  in  i  ;  stomach  (cardiac 
part)  in  i  ;  and  pancreas  in  i.  The  following  were  the 
bones  affected  :  both  clavicles  and  tibiae,  the  vertebrae  and 
other  bones,  the  sphenoid  and  base  of  skull,  each  in  one  case. 
Thus  of  these  10  necropsies  there  were  metastatic  deposits 
in  the  bones  in  30  per  cent. 

Secondary  Deposits  in  the  Bodies. — Of  88  cases  secondary 
deposits  in  the  bones  were  noticed  in  5.  Subjoined  are  brief 
abstracts  of  these  cases  : — 

(i)  The  patient,  aged  42,  had  a  mass  of  hard  cancer,  the  size  of  a  hen's 
egg,  occupying  his  right  breast,  which  infiltrated  the  overlying  skin  and  the 
axillary  glands.  It  was  of  eight  years'  duration.  The  breast  was  amputated 
and  the  axilla  cleared  out.  On  microscopical  examination  alveolar  fibrous 
cancer  was  found.  Three  months  later  there  was  recurrence  of  the  disease 
in  the  chest.  Shortly  afterwards,  in  raising  his  arm,  spontaneous  fracture 
of  the  right  clavicle  occurred,  and  at  the  seat  of  fracture  a  cancerous  tumour 


412  CANCER    OF    THE    MALE    BREAST. 

soon  formed.  Subsequently  cancerous  growths  developed  in  both  tiblse.  He 
died  of  asthenia  a  year  after  the  operation  for  the  primary  disease.  At  the 
necropsy  the  whole  of  the  soft  parts  of  the  right  mammary  region  were  exten- 
sively infiltrated  by  a  dense  fibroid  cancerous  growth,  which  had  invaded 
the  subjacent  ribs  and  the  sternum  by  direct  extension.  There  were 
secondary  deposits  in  both  clavicles  and  tibiee,  as  well  as  in  the  liver. 

(2)  The  patient,  aged  40,  came  under  observation  with  ulcerated  scirrhus 
of  the  breast,  and  extensive  nodular  infiltration  of  the  skin  and  adjacent  soft 
parts  and  axillary  glands.  The  disease  was  of  five  years'  duration.  He 
died  shortly  afterwards  with  secondary  deposits  in  the  sphenoid  and  base  of 
skull. 

(3)  This  man,  aged  45,  had  a  hard  nodular  cancer  of  the  right  breast,  with 
infiltration  of  the  overlying  skin  and  axillary  glands.  No  operative  treat- 
ment was  undertaken.  He  died  with  extensive  cancerous  growths  in  the 
vertebra  and  other  bones.  The  total  duration  of  the  disease  was  thirteen 
months. 

(4)  The  disease  began  as  a  hard  nodule,  the  size  of  a  marble,  in  the  right 
breast,  a  year  before  the  patient  came  under  observation.  It  soon  increased 
to  the  size  of  a  walnut,  and  ^the  axillary  glands  became  enlarged.  The 
patient,  whose  age  was  45,  was  emaciated  ;  and,  after  he  had  been  under 
treatment  but  a  short  time,  he  sustained  spontaneous  fracture  of  the  right 
humerus  at  its  lower  third  when  turning  in  bed.  About  this  time  he  com- 
plained of  pain  in  all  the  limbs  ;  and  he  died  shortly  afterwards  with 
symptoms  of  secondary  disease  of  the  lungs. 

(5)  This  patient,  aged  48,  had  ulcerated  scirrhous  cancer  of  the  left  breast 
of  four  months'  duration,  and  a  cancerous  growth  of  the  left  clavicle. 

I  will  now  conclude  with  brief  abstracts  of  some  cases  of 
cutaneous  epithelioma,  and  tubular  cancer. 

Cutaneous  Epithelioma  of  the  Male  Mamma. — Of  this  there 
were  in  my  list  the  three  following  cases  : — 

(i)-  The  patient,  aged  63,  came  under  treatment  with  a  hard  cancerous 
ulcer  of  the  mammary  region  the  size  of  a  walnut.  It  was  of  a  year's  dura- 
tion, and  ulceration  began  after  the  disease  had  existed  for  six  months.  He 
had  experienced  several  haemorrhages  from  it.  The  disease  was  extirpated. 
The  histological  examination  was  made  by  Cornil,  who  described  it  as  an 
e\a.m'^\&  oi  ^'' epiihdlio>ne pavimenteux  lobul^"  which  probably  originated  in 
the  skin  of  the  areola. 

{2f  The  age  of  the  patient  was  47.  He  came  under  treatment  with  a 
hard  cancerous  ulcer  of  the  breast  and  infiltration  of  the  axillary  glands. 
The  disease  was  first  noticed  five  years  previously  as  a  hard  lump  at  the  left 
nipple.  Ulceration  began  eighteen  months  ago.  On  microscopical  exam- 
ination it  proved  to  be  "  squamous-celled  carcinoma." 


'  Bernadet's  case,  quoted  by  Horteloup. 

'Barling's  case,  Brit.  Med.  Journ.,  vol.  i.,  1887,  p.  883. 


CANCER  OF  THE  MALE  BREAST.  413 

(3)^  A  tall,  thin,  dark,  neurotic  man,  aged  41,  came  under  observation  with 
epitheliomatous  ulceration  of  the  areola,  in  the  midst  of  which  the  nipple 
was  still  visible.  The  disease  seemed  to  consist  of  indurated  _^/«^/^^i-  in  the 
skin,  which  were  movable  over  the  subjacent  soft  parts.  In  the  edges  and 
base  of  the  ulcer  a  blackish  tint  was  obvious.  The  axillary  glands  were 
enlarged.  He  stated  that  the  disease  began  five  years  previously  as  a  small 
wart  in  the  skin  of  the  areola  ;  ulceration  set  in  six  months  ago.  His 
mother  died,  aged  60,  of  "  cancer  of  the  bowels."  His  previous  health  had 
been  good,  although  he  had  suffered  from  dyspepsia  and  emphysema.  He 
had  led  a  regular  life  under  favourable  conditions.  The  breast  was  ampu- 
tated, and  the  axillary  glands  removed.  On  microscopical  examination  it 
proved  to  be  a  case  of  melanotic  cancer  of  the  skin  of  the  areola,  and  the 
axillary  glands  were  similarly  affected.  The  patient  recovered  from  the 
operation,  but  recurrence  set  in  before  complete  healing  of  the  wound.  This 
was  destroyed  by  Vienna  paste  ;  but  it  rapidly  recurred  in  the  chest  and 
axilla.  One  year  after  the  first  operation  he  was  in  a  moribund  condition, 
with  extensive  recurrent  disease  invading  the  thorax  and  secondary  disease 
of  the  liver.* 

Le  Dentu^  has  met  with  an  interesting  case  of  "  Epith^liome 
pavimenteux  lobule,  come,  d'apparence  calcifiee  "  of  the  areola  in  a 
man  aged  44  ;  and  Robinson*^  has  lately  recorded  an  instance 
of  rodent  ulcer  of  the  male  nipple. 

The  following  example  of  "•  Pagefs  disease''  of  the  male 
nipple  is  by  Forrest.^ 

The  patient,  72  years  old,  nine  months  ago  first  noticed  that  a  lactescent 
secretion  escaped  from  his  right  nipple.  This  dried  and  formed  a  scab,  on 
removing  which,  the  subjacent  skin  was  found  red  and  eroded,  and  fresh 
scabs  soon  formed.  Three  months  later  retraction  of  the  nipple  set  in  ;  and 
shortly  afterwards  enlarged  glands  were  noticed  in  the  axilla.  On  examina- 
tion six  months  later  scirrhous  cancer  was  found  to  have  developed  in  the 
breast. 

Nunn®  has  seen  a  case  of  ulcerated  cancer  over  the  sternum  in  a  man 
aged  62  ;  the  disease  was  first  noticed  ten  years  previously,  when  it 
appeared  as  "  a  small  scaly  patch." 

Tubular  Cancer  of  the  Male  Mamma. — As  examples  of  this 

condition,  abstracts  of  the  following  cases  will  suffice  : — 

(i)  This  patient  came  under  my  own  observation.  He  was  a  well- 
nourished,  dark  complexioned,  sallow  man,  aged  64,  a  joiner  by  trade.     One 

^  Chenet's  case,  quoted  by  Poirier,  p.  50. 

*  For  other  examples  of  melanosis  of  the  male  breast  vide  p.  333. 

5  Bull.  et.  Mhii.  de  Soc.  de  la  Chir.,  1885,  t.  ix.,  p.  1887. 

«  Trans.  Path.  Soc,  1893. 

"  Glas.  Med.  Journ.,  vol.  xiv.,  p.  457. 

^  "  Cancer  of  Breast,"  p.  1 18. 


414  CANCER  OF  THE  MALE  BREAST. 

and  a-half  years  previously  he  first  noticed  a  hard  lump,  the  size  of  a 
marble,  beneath  the  right  nipple.  There  had  been  no  previous  injury  or 
disease  of  the  part.  His  previous  health  had  been  very  good,  with  the 
exception  of  a  severe  attack  of  eczema — fourteen  years  ago — which  involved 
almost  the  whole  body.  He  continued  to  be  subject,  more  or  less,  to  this 
affection,  until  the  present  disease  began.  There  was  no  history  of  cancer 
or  phthisis  in  the  family.  On  examination  I  found  that  the  right  nipple  and 
areola  had  completely  disappeared :  in  their  place  was  a  cancerous  ulcer, 
2|  by  li  inches.  Its  edges  and  base  were  hard,  and  the  former  raised  and 
knobby.  Beneath  this  ulcer  was  a  mass  of  hard  growth,  slightly  adherent 
to  the  subjacent  parts.  A  mass  of  cancerous  glands  occupied  the  right 
axilla.  About  various  parts  of  the  body,  but  especially  at  the  back  of  the 
lower  part  of  the  neck,  were  numerous  small  warty,  fibromatous  and  varicoid 
outgrowths.  The  diseased  breast  was  extirpated,  together  with  a  large  poi"- 
tion  of  the  pectoral  muscle  ;  and  the  axilla  was  cleared  out.  Erysipelas 
supervened  on  the  twelfth  day  after  the  operation,  followed  by  acute  double 
septic  pleurisy,  and  collapse  of  the  lungs,  of  which  he  died.  At  the  necropsy 
the  body  was  fairly  nourished.  The  partially  healed  operation  wound 
occupied  the  right  thoracic  region  and  the  axilla.  The  right  upper  limb  was 
oedematous.  On  careful  dissection  this  proved  to  be  due  to  thrombosis, 
which  had  extended  from  the  subscapular  vein  ;  starting  from  the  point  at 
which  it  had  been  ligatured  during  the  operation,  the  thrombosis  had  spread 
to  the  axillary  vein,  and  thence  to  all  its  tributaries  of  the  upper  limb  as 
far  as  the  wrist.  At  the  extreme  apex  of  the  axilla  a  few  cancerous  glands 
were  found  ;  and  also  beneath  the  pectoralis  minor.  Recent  double  acute 
pleurisy  with  effusion,  and  collapse  of  the  lower  lobes  of  both  lungs.  The 
liver  large  and  fatty.  Double  chronic  interstitial  nephritis.  On  micro- 
scopical examination,  the  mammary  growth  proved  to  be  tubular  cancer 
the  tubular  structures  being  hollow  and  lined  with  but  a  single  layer  of  sub- 
columnar  epithelium. 

(2)  This  and  the  following  case  are  by  Courtade.'  The  patient  was  a 
locksmith,  aged  56.  Four  months  ago  he  felt  pain  in  his  right  breast,  and 
soon  afterwards  he  noticed  a  tumour  there,  the  size  of  a  hazel-nut.  There 
was  no  history  of  syphilis.  His  family  history  was  free  from  any  cancerous 
taint.  On  examination,  a  small,  hard  tumour  was  found  beneath  the  right 
nipple,  which  was  retracted.  There  was  no  enlargement  of  the  axillary 
glands.  The  diseased  breast  was  amputated.  The  patient  was  convalescent 
in  fourteen  days.  On  histological  examination  of  the  mammary  tumour,  it 
was  found  to  consist  of  duct-like  structures,  lined  with  a  single  layer 
of  cubical  epithelium. 

(3)  Here  the  patient  was  a  stone  sawyer,  aged  46,  who  five  months 
previously  first  noticed  a  small  area  of  induration  in  his  right  breast.  He 
attributed  it  to  pressure  of  the  saw  at  his  work.  There  was  no  family 
history  of  cancer.  His  previous  health  had  been  good.  On  examination  a 
rounded  tumour,  the  size  of  a  walnut,  was  found  beneath   the  nipple  of  his 


'■*  L' Union  MeJicale,  1885,  t.  xl.,  p.  1070. 


CANCER    OF    THE    MALE    BREAST.  415 

right  breast,  but  the  nipple  was  not  retracted.  There  was  no  obvious 
enlargement  of  the  axillary  glands.  The  diseased  breast  was  amputated, 
and  he  was  convalescent  in  18  days.  He  returned  i^^  months  later  with  a 
tumour  the  size  of  a  hazel-nut  in  his  left  breast,  which  he  first  noticed  a 
fortnight  ago.  It  was  intimately  connected  with  the  nipple.  This  breast 
also  was  amputated,  and  he  left  convalescent  10  days  later.  On  histological 
examination  the  growth  consisted  of  duct-like  structures,  lined  by  cells  of 
columnar  type. 

(4)'°  In  this  case  the  disease  presented  as  a  bossy  tumour,  adherent  to 
the  overlying  skin,  but  movable  over  the  subjacent  pectoral  muscle.  His- 
tologically it  was  composed  of  fibrous  stroma,  in  which  were  embedded 
duct-like  structures,  lined  peripherally  with  cells  of  columnar  type,  within 
which  were  flattened  cells.  It  is  described  by  the  author  as  "  epitheliome 
cylindrique  a  tubes  allonges." 

(5)"  A  "  concierge"  aged  60,  three  years  ago  first  noticed  a  small 
tumour  beneath  the  areola  of  his  left  breast ;  two  years  later  it  began  to 
ulcerate.  His  previous  health  had  been  good,  but  seven  years  ago  he  had 
an  attack  of  "shingles"  in  the  left  side,  at  about  the  level  of  the  mamma,  and 
he  had  for  many  years  been  subject  to  migraine.  There  was  no  history  of 
cancer  in  his  family.  When  first  seen  he  was  well  nourished,  and  in  good 
health.  A  hard,  nodular,  circumscribed  tumour  (12  by  8  cm.)  occupied  the 
left  mammary  region.  Its  central  projecting  part  was  eroded,  over  an 
area  the  size  of  a  crown  piece.  The  overlying  skin  was  adherent,  but  the 
tumour  was  movable  on  the  subjacent  parts.  The  axillary  glands  were  not 
obviously  affected.  The  diseased  part  was  amputated.  Recovery  was 
delayed  by  slowness  of  cicatrisation.  Eight  months  later  two  small  re- 
current nodules  had  appeared  in  the  scar,  but  the  axillary  glands  were  free. 
Four  months  later  this  recurrent  disease  was  excised.  Several  recurrences 
subsequently  took  place  at  the  primary  seat,  and  finally  in  the  axillary 
glands.  Histologically  the  primary  disease  was  tubular  cancer,  but  some 
of  the  recurrent  growths  were  of  quasi-acinous  type. 

(6)^^  A  coachman,  aged  56,  nine  months  ago  noticed  sanious  discharge 
from  his  right  nipple,  and  a  small  hard  nodule  beneath  this  part.  Six  weeks 
ago  the  tumour  had  attained  the  size  of  two  fists.  It  was  then  tapped,  and 
a  large  quantity  of  blood-stained  fluid  was  evacuated.  No  previous  injury 
or  disease  of  the  part.  When  he  came  under  observation  the  right  breast 
was  occupied  by  a  tumour,  the  size  of  a  tangerine  orange,  situated  beneath 
the  nipple,  which  was  retracted.  The  tumour  was  of  ovoid  shape,  fluctuatino 
in  parts,  and  lobulated.  It  was  adherent  to  the  overlying  skin,  but  movable 
over  the  subjacent  parts.  There  were  several  enlarged  hard  glands  in  the 
axilla.  The  breast  was  amputated,  and  the  axilla  cleared.  He  was  con- 
valescent 15  days  later.  The  mammary  tumour  contained  numerous  cysts. 
Histologically,  it  consisted  of  cylinder-celled  duct-like  structures,  "  Epithe- 
liome intra-canaliculaire." 


'"  Marcowitz,  Bull,  de  la  Soc.  Anat.,  i860,  p.  134. 
"  Thorens,  V Union  Medicale,  1881,  No.  7,  p.  74. 
'-  Bull,  de  la  Soc.  Anal..,  1892,  p.  7S0. 


41 6         CANCER  OF  THE  MALE  BREAST. 

(yy^  This  patient,  aged  57,  three  years  previously  first  noticed  yellowish 
discharge  from  his  nipple,  and  a  lump  beneath.  On  examination  a  cir- 
cumscribed spheroidal  tumour  (2"5  by  i'5  cm.)  presented  beneath  the 
nipple,  with  which  it  was  closely  related.  On  examination  after  removal  it 
was  found  to  be  enclosed  in  a  fibrous  capsule,  which  adhered  closely  to 
the  surrounding  tissues.  On  section  it  was  of  firm  consistence,  and  quasi- 
alveolar  structure.  Histological  examination  revealed  a  mass  of  hollow 
tubular  structures,  lined  by  a  single  layer  of  columnar  cells.  Nothing  is 
said  about  the  condition  of  the  axillary  glands. 

Similar  case.s  have  been  recorded  by  Hermann  and  Tourneux,^* 
Gross,^^  Baccialli,^^  Robinson^^  and  others. 

For  further  information  about  neoplasms  of  the  male  breast 
reference  should  be  made  to  the  publications  of  Schuchardt,^^ 
Poirier,^^  Horteloup,^*^  Wagstaffe,^^  and  Pemberton.^^ 


"  Shattock,  Tram.  Path.  Soc,  1892,  p.  119. 

'*  Journal  de  rAnat.  et  de  la  Physiol.^  1876,  xii. ,  p.  607. 

'^  "  Carcinoma  recurring  in  the  Axillary  Glands  after  excision  of  a  Tubular  Cancer 
of  the  Male  Mamma,"  Phil.  Med.  News,  1880,  x.,  p.  261. 

'"  Revsita  Clmica  de  Bologna,  Dec,  1887,  p.  833. 

"  Trans.  Path.  Soc,  1890,  p.  227.  This  patient  had  also  squamous  epithelioma 
of  the  tongue. 

'"  Arch.  f.  klin.  Chir.,  Bd.  xli.,  1891,  S.  64  ;  Bd.  xxxii.,  Heft  2,  1885  ;  and  Bd. 
xxxi.,  Heft  I,  1884. 

'"  "Tumeurs  du  sein  chez  I'homme,"  Paris,  1883. 

-"  "  Des  tumeurs  du  sein  chez  I'homme,"  Paris,  1872. 

^'  Trans.  Path.  .Soc,  vol.  xxvii.,  p.  234. 

'^-  "  Clinical  lUust.  of  Cancer,"  p.  14,  &c. 


417 


CHAPTER    XVII. 
Sarcoma  of  the  Breast. 


Sarcoma  of  the  breast  is  a  rather  rare  disease.  Of  13,824 
primary  neoplasms  analysed  by  me  (males,  4,593  ;  females, 
9,227),  1,081  were  sarcomata  (males,  559  ;  females,  552) ;  and  of 
the  latter,  only  99  were  of  the  breast  (males,  5  ;  females,  94). 

The  account  I  have  to  give  of  this  disease  is  mainly  based 
upon  the  study  of  30  cases,  7  of  which  are  of  my  own  recording,^ 
supplemented  by  reference  to  the  analyses  of  Schuoler,-  Gross,^ 
Poulsen,*  and  Schmidt.^ 

As  I  have  elsewhere  pointed  out,*^  the  relative  liability  of  the 
female  breast  to  sarcomatous  growths  is  much  below  the  average 
for  the  body  in  general ;  9*4  per  cent,  of  the  body  neoplasms 
being  sarcomatous,  whereas  only  3*9  per  cent,  of  female  breast 
neoplasms  are  of  this  nature. 

The  feature  that,  more  than  any  other,  especially  attracts 
attention  in  connection  with  this  disease  is  the  great  rarity  of 
its  occurrence,  as  compared  with  cancer.       Of  2,397  consecutive 


'  Of  the  others,  lo  are  from  the  University  College  Hospital  Reports  (1S84-S9),  7 
from  the  Middlesex  Hospital  Reports  (1875-81),  and  6  are  from  Bryant's  work  on 
"  Diseases  of  the  Breast,"  p.  124,  et  seq. 

- "  Beitriige  z.  klin.  Bikle  des  Brustdriisensarcoms,"  Corresp.-Bl.  f.  schw. 
u^rzte,  1890,  S.  283. 

^  "American  Syst.  Gyn.,"  vol.  ii. ,  p.  226. 

•*  Arch.f.  klin.  Chir.,  xlii.,  189 1,  S.  593. 

^  Beitrage  z.  klin.  Chir.,  iv.,  S.  40,  1888-9. 

*"The  Varieties  of  Mammary  NeopLisms  and  their  Relative  Frequency," 
British  Medical  Journal,  September  10,  1892. 


27 


41 8  SARCOMA    OF    THE    BREAST. 

neoplasms  of  the  female  breast  analysed  by  me,  1,863,  or  777 
per  cent,  were  cancers  ;  while  only  94,  or  3-9  per  cent.,  were 
sarcomata.  This  shows  the  much  greater  stability  of  the  para- 
blastic  as  compared  with  the  archiblastic  elements  of  the  gland. 
The  great  majority  of  mammary  sarcomata  arise  in  the 
immediate  vicinity  of  the  small  ducts  (adeno-sarcomata)  ;  only 
rarely  do  they  originate  elsewhere  (pure  sarcomata).  This  is 
the  more  remarkable  when  we  recollect  the  great  abundance  of 
fibro-adipose  tissue  that  goes  to  make  up  the  breast,  which  else- 
where is  such  a  favourite  starting-point  for  these  growths.  More- 
over, the  mammary  integument  enjoys  even  more  complete  ex- 
emption from  sarcoma  than  it  does  from  carcinoma  ;  for  with  the 
exception  of  a  few  rare  cases  of  keloid,  I  know  of  hardly  any 
other  instances  of  sarcoma  originating  from  it.  The  matrix 
tissue  of  the  initial  proliferative  changes,  usually  is  the  layer  of 
hyaline  substance  immediately  surrounding  the  epithelial  invest- 
ment of  the  small  ducts,  which  is  but  a  myxomatous  modi- 
fication of  the  adjacent  connective  tissue,  consisting  of  a  net- 
work of  flattened,  branching,  nucleated  cells,  embedded  in 
hyaline  stroma.  Owing  to  the  intimate  genetic  relationship 
thus  subsisting  between  the  morbid  growth  and  the  glandular 
structures,  the  latter  are  usually  involved  in  sarcomatous  neo- 
plasms. This  close  association  of  the  disease  with  the  glandular 
elements  seems  to  indicate,  that  it  is  in  some  way  an  outcome 
of  functional  aberration. 

The  question  has  been  much  discussed  whether  the  glandular 
structures  met  with  under  these  circumstances  are  of  neoplastic 
origin,  or  whether  they  are  merely  the  outcome  of  the  mechanical 
distortion  of  pre-existing  structures.  From  the  fact  that  they 
have  often  been  found  within  intra-cystic  growths  several  inches 
long,  it  seems  to  me  that  their  ectasic  origin — in  such  cases  at 
least — -must  be  admitted.  Nevertheless,  it  seems  certain,  from 
considerations  presently  to  be  mentioned,  that  these  proliferous 
glandular  structures  do  not  form  an  essential  element  of  the 
disease.  The  term  adeno-sarcoma,  given  by  I^illroth  to  growths 
thus  constituted,  is,  however,  a  good  one ;  and   it  ought  to  be 


STATISTIC :A L    S  U  M  M  A  R I  KS. 


419 


retained.  Some  idea  of  the  relative  frequency  of  the  occurrence 
of  adeno-sarcoma  and  pure  sarcoma,  and  of  their  structural 
peculiarities,  may  be  gathered  from  the  subjoined  analysis  of 
the  30  cases  comprised  in  my  list. 

In  21  of  these  cases  the  disease  was  primary,  and  in  9  recurrent. 

Of  the  primary  group,  17  were  adeno-sarcomata,  and  4  contained  no 
glandular  elements. 

Of  the  adeno-sarcomata,  in  10  there  were  cysts  with  intra-cystic  growths, 
and  in  7  no  cysts  were  obvious  to  the  naked  eye. 

Of  the  cystic  cases,  in  3  the  sarcomatous  disease  presented  as  round  and 
spindle-celled  tissue,  in  2  it  was  round-celled,  in  i  round-celled  and  myxo- 
matous, in  I  spindle-celled,  and  in  3  cases  its  exact  characters  were  not 
specified. 

Of  the  non-cystic  cases,  in  4  spindle  cells,  in  2  spindle  and  round  cells, 
and  in  i  round  cells  alone,  predominated. 

It  will  be  gathered  from  this  that  in  the  cystic  adeno-sarcomata  round 
cells  predominate,  whereas  in  the  non-cystic  forms  spindle  cells  are  of  more 
frequent  occurrence. 

Of  the  4  primary  sarcomata  in  which  no  glandular  elements  were  found, 
2  were  mainly  composed  of  round  and  spindle  cells,  i  of  round  cells,  and  i 
was  an  alveolar  sarcoma. 

Of  the  recurrent  group,  in  2  cases  the  neoplasms  contained  gland  ele- 
ments, and  in  7  none  could  be  found.  Of  the  latter  cases,  in  5  the  new 
growth  was  round-celled,  in  i  spindle- celled,  and  in  i  alveolar.  Of  the 
former  cases,  in  i  the  sarcomatous  tissue  was  round-celled,  and  in  the  other 
its  exact  character  was  not  stated. 


§  y 


-Statistical  Summaries. 


An  analytical  summary  of  my  12  cases  of  cystic  adeno- 
sarcoma  gives  the  following  results  : — 

Age. — The  earliest  age  at  which  the  disease  was  first  noticed 
was  23"5  years  ;  the  latest,  59"2  years  ;  the  mean  age,  44'8  years. 
The  numbers  for  each  quinquennial  period  were  as  follows  : — 


20  to  25  years 

30  „  35  » 

35  »  40  „ 

40  „  45  » 

45  »  50  „ 

50  »  55  „ 

55  ,.  f^o  V 


Duration. — Of  9  primary  cases,  the  duration  of  the  disease 


m  I  case. 

1  » 

2  cases. 
I  case. 

3  cases. 


420  SARCOMA    OF    THE    BREAST. 

from  the  time  it  was  first  noticed  until  the  patient  came  under 
treatment,  was  as  follows  : — The  shortest  period,  i  month  ;  the 
longest,  6  years  ;  the  mean  duration,  31*4  months.  In  the  two 
fatal  cases  the  total  duration  of  life  was  68"8  months  (large 
round-celled  sarcoma),  and  28"5  months. 

Civil  State. — Married,  6  ;  widowed,  2  ;  single,  3. 

Occupation. — Of  4  married,  all  were  housewives  ;  of  2  widows, 
I  was  a  nurse,  the  other  a  housekeeper ;  of  the  3  single,  i  was 
a  cook,  I  a  servant,  and  i  a  governess. 

Pregnancy,  &c. — Of  7  who  had  lived  in  wedlock,  2  were 
barren  (never  pregnant) ;  i  of  these  had  not  married  until  the 
age  of  42,  and  she  only  cohabited  with  her  husband  nine  months. 
Of  the  others  i  had  only  2  miscarriages  (she  had  cohabited  with 
her  husband  for  many  years)  ;  all  the  other  4  were  prolific  :  i 
had  12  children  and  4  miscarriages,  another  8  children,  another 
4,  and  another  3. 

Catamenia. — Of  5  cases  in  which  inquiries  were  made,  all 
had  been  regular  (profuse,  2).  Puberty  supervened  (in  2  cases) 
at  15  and   16;  and  the  climacteric  (in  3  cases)  at  47'5,  49,  and 

51. 

TJie  Side  Affected. — The  right  breast  in  7  cases,  the  left  in  5. 

The  Original  Site  of  the  Disease. — In  the  central  part  of  the 
breast  in  5  cases  ;  and  in  the  peripheral  parts  in  5  (lower  and 
axillary  3,  upper  i,  lower,  i).  In  one  case  when  the  disease 
was  first  noticed  it  consisted  of  two  separate  nodules  ;  in  all  the 
other  cases  the  initial  manifestation  was  a  solitary  nodule. 

Previous  Injury  or  Disease  of  the  Breast. — Of  8  cases  in 
which  inquiries  were  made  there  was  history  of  previous  injury 
or  disease  in  2.  In  one  of  these  cases  the  nipple  was  congeni- 
tally  retracted,  and  there  had  been  an  induration  of  the  breast 
for  20  years,  which  supervened  after  a  milk  abscess.  In  this 
case  the  disease  was  first  noticed  a  month  after  a  contusion  of 
the  part  in  moving  an  iron  bedstead.  In  the  other  case  the 
onset  of  the  disease  was  attributed  to  a  strain  in  lifting.  In  one 
case  a  small  tumour  that  had  existed  in  the  breast  for  over  five 
years,   attained   a  large  size  in  the  course  of  several  months, 


STATISTICAL    SUMMARIES.  42  1 

under  the  influence  of  pregnancy.  This  was  the  only  case  in 
which  pregnancy  appeared  to  have  played  an  important  part  in 
the  evolution  of  the  disease. 

Previous  Health, — Of  7  cases  the  previous  health  had  been 
good  in  all ;  but  one  of  these  patients  had  suffered  from  three 
attacks  of  rheumatic  fever,  from  typhoid  fever,  and  from  small- 
pox. Another  of  them  had  suffered  from  smallpox  and  bron- 
chitis ;  the  others  had  been  free  from  any  serious  disease  since 
childhood. 

Family  History. — The  Fathers.  Of  10  cases  in  which  inquiries  were 
made,  in  8  the  fathers  were  dead.,  and  in  2  they  were  still  alive  and  well 
(i  aged  n). 

The  causes  of  death  were  : — Phthisis,  i  ;  typhoid  fever,  i  ;  accident,  i  ; 
old  age,  I  ;  and  unknown,  4.  The  ages  at  death  were  44,  52,  64,  65,  72,  76, 
and  81. 

The  Mothers. — Of  10  mothers  9  were  dead.,  and  i  was  still  alive  and 
well.  The  causes  of  death  -were  :  malignant  disease  of  the  breast,  i  ; 
phthisis,  I  ;  childbed,  i  ;  bronchitis,  i  ;  old  age,  i  ;  unknown,  2.  The 
ages  at  death  were — under  30,  40,  60,  64,  70,  and  79. 

Consanguinity  in  the  Parents. — As  to  this,  inquiries  were  made  in  three 
cases  with  negative  results. 

The  Patients  Brothers  and  Sisters. — In  eight  families  the  following 
causes  of  death  were  noted  among  the  adults  : — Phthisis  (i  or  more  deaths) 
in  four  families,  apoplexy  in  one  family,  and  in  one  family  the  patient's 
brother  died  of  tumour  of  the  liver.  The  number  of  members  in  each 
family  were  as  follows  : — 2,  4,  7  (3  instances),  12,  and  14. 

The  Occurrence  of  Malignant  Disease.  —  Of  11  families, 
there  was  history  of  malignant  disease  in  3.  In  one  case 
the  sister  of  patient's  mother  died  of  malignant  disease  of  the 
breast ;  in  another  case  the  patient's  mother  died,  aged  33,  of 
malignant  disease  of  the  breast  ;  in  the  other  case  the  patient's 
maternal  grandfather  died  of  cancer  of  the  chin.  In  one  case 
the  patient's  brother  died  of  tumour  of  the  liver,  of  nature 
unknown.  In  the  two  families  in  which  relatives  had  died  of 
malignant  disease  of  the  breast,  there  was  history  of  phthisis 
as  well. 

The  Occurrence  of  Phthisis. — Of  10  families,  one  or  more 
of  the  adults  had  died  of  phthisis  in  4 ;  in  one  family  the 
father    and    2  of  the    patient's   brothers  died   of  phthisis    (the 


422  SARCOMA    OF    THE    BREAST. 

patient's  mother  died  of  malignant  disease  of  the  breast);  in 
another  family  the  father's  mother  and  several  of  his  brothers 
and  sisters,  as  well  as  the  patient's  brother,  all  died  of  this 
disease. 

TJie  Occurrence  of  Insanity.  —  Inquiries  were  made  in  2 
cases  with  negative  results. 

State  on  Examination.  —  Of  6  primary  cases,  4  were 
well  nourished  and  healthy-looking  (obese  i),  and  2  were 
moderately  nourished. 

The  complexion  was  noted  in  4  cases — 2  were  dark  and  2  fair. 
Of  9  primary  cases,  in  5  the  overlying  skin  was  adherent  and 
reddened,  and  in  i  of  them  it  was  ulcerated  and  invaded  by 
the  disease.  The  superficial  cutaneous  veins  were  markedly 
enlarged  in  4  cases.  In  one  case  the  nipple  was  congeni- 
tally  stunted,  and  in  another  it  was  obliterated  by  stretching; 
but  in  no  case  was  it  retracted,  as  in  cancer.  The  tumours 
were  generally  of  large  size — mostly  as  large  as  a  good-sized 
turnip ;  the  smallest  was  the  size  of  a  walnut,  the  largest  of  a 
man's  head.  They  were  generally  circumscribed  and  of  irregu- 
larly rounded  shape,  lobulated  and  nodular.  In  not  a  single 
instance  did  the  tumour  adhere  to  the  subjacent  pectoral 
muscle. 

With  regard  to  the  axillary  glands,  in  the  10  primary  cases, 
these  were  slightly  enlarged  in  2,  and  normal  in  8  ;  of  the 
2  recurrent  cases,  in  one  the  glands  were  invaded,  and  in  the 
other  they  were  free. 

Treatment  and  Result. — Of  10  primary  cases,  in  9  the 
breast  was  freely  removed,  together  with  the  overlying  adherent 
skin  in  5  cases,  and  in  one  case  slightly  enlarged  axillary  glands 
were  also  removed.  All  these  patients  recovered  from  the 
operation,  the  periods  of  convalescence  being  13,  16,  19,  25, 
37,  47,  70,  and  90  days.  The  subsequent  history  of  2  of  them 
is  recorded  : — 

(i)  In  this  case  the  patient,  aged  52,  came  under  treatment  with  a  large 
lobulated  cystic  sarcoma  of  the  left  breast,  of  ten  months'  duration,  the 
axillary  glands  being  unaffected.     The  diseased  breast  was  freely  removed. 


STATISTICAL    SUMMARIES.  423 

After  a  tedious  convalescence  of  seventy  days,  the  patient  passed  from 
observation  before  the  wound  had  c|uite  healed.  Soon  afterwards  recurrence 
set  in.  Six  weeks  later,  the  whole  of  the  left  pectoral  region  was  found  to 
be  infiltrated  with  recurrent  disease,  which  in  some  places  had  ulcerated. 
The  axillary  and  other  adjacent  glands  were  unaffected.  No  further  opera- 
tion was  done.  She  died  of  asthenia  about  a  month  later.  At  the  necropsy 
no  secondary  growths  were  found. 

(2)  The  patient,  aged  50,  came  under  observation  with  a  large  nodulated 
elastic  tumour  of  the  right  breast,  of  three  years'  duration.  The  overlying 
skin  was  adherent,  but  the  mass  was  movable  on  the  subjacent  pectoral 
muscle.  The  axillary  glands  were  normal.  The  breast  was  amputated 
with  the  tumour  ;  and  the  overlying  skin,  together  with  a  portion  of  the 
sheath  of  the  pectoralis  major  muscle,  was  also  removed.  The  axilla  was 
not  touched.  The  tumour  was  a  large  round-celled  adeno-cystic  sarcoma, 
imperfectly  encapsuled.  The  patient  passed  from  under  treatment  sixteen 
days  later.  She  was  next  seen  nine  months  later,  when  there  was  recurrence 
of  the  disease  at  the  primary  seat,  the  axilla  being  normal.  The  recurrent 
disease  was  then  excised,  and  the  patient  went  away  convalescent  twenty 
days  afterwards.  One  year  later  she  again  came  under  observation,  with  a 
recurrent  tumour,  the  size  of  an  orange,  in  the  right  axilla,  of  two  months 
duration,  the  pectoral  region  being  quite  free  from  disease.  The  axillary 
growth  was  freely  dissected  out.  It  was  encapsuled,  and  otherwise  of 
similar  structure  with  the  primary  growth.  The  patient  went  away  con- 
valescent fourteen  days  after  the  operation.  Five  months  later  she  again 
came  under  observation,  with  extensive  recurrence  in  the  axilla,  the  pectoral 
region  still  being  quite  free.  No  further  operation  was  done.  She  died  of 
asthenia  ninety-eight  days  later.  At  the  necropsy  the  axillary  glands  and 
adjacent  structures  were  found  to  be  extensively  infiltrated  by  the  disease, 
as  well  as  the  lower  cervical  glands.  The  subclavian  artery  was  compressed 
by  the  growth,  with  consequent  dry  gangrene  of  the  whole  upper  limb,  as  far 
upwards  as  two  inches  above  the  elbow.  The  axillary  part  of  the  thoracic 
wall  was  invaded  by  direct  extension,  and  the  adjacent  pleura  infiltrated. 
There  were  no  metastases.  The  pectoral  region  was  quite  free  from 
recurrent  disease. 

In  only  one  of  the  primary  cases  was  the  growth  excised 

without  removing  the  breast. 

The  patient  was  a  woman,  aged  36,  whose  left  breast  was  occupied  by  a 
larcre  adeno-cystic  sarcoma,  which  extended  chiefly  downwards  and  outwards 
towards  the  axilla,  where  an  enlarged  gland  could  be  felt.  The  tumour,  which 
after  removal  weighed  2lbs.  40Z.,  was  excised  without  the  breast,  and  the 
enlaro-ed  axillary  gland  was  also  dissected  out.  She  remained  free  from  any 
return  of  the  disease  for  two  years,  and  in  the  interval  had  a  child,  which  she 
wassucklino-  with  this  breast,  when  she  first  noticed  a  small  lump,  just  above 
the  nipple  and  the  old  cicatrix.  In  the  course  of  a  year  this  developed  into 
a  large  lobulated  recurrent  growth.  It  was  then  excised  together  with  the 
whole  of  the  breast.     In  its  gross  characters  the  recuri'ent  tumour  resembled 


424  SARCOMA    OF    THE    BREAST. 

the  primary  one.     When  last  heard  of,  two  years  later,  she  was  quite  well 
and  free  from  any  return  of  the  disease. 

The  history  of  the  two  cases  that  came  under  treatment  with 

recurrent  disease  is  briefly  as  follows  : — 

(a)  Three  months  after  excision  of  the  primary  disease,  which  was  of  five 
months'  duration,  without  removal  of  the  breast,  recurrence  took  place  at  the 
primary  seat.  A  few  months  later  the  whole  breast  was  removed,  together 
with  the  recurrent  disease.  A  month  later  there  was  rapidly  growing  re- 
currence in  the  axilla.  The  disease  was  soon  afterwards  freely  dissected  out 
from  this  region,  and  as  the  scar  in  the  mammary  region  appeared  somewhat 
thickened,  it  was  also  excised.  The  recurrent  disease  was  small  round- 
celled  sarcoma.  The  patient  went  away  convalescent  fifty-three  days  later, 
and  nothing  further  was  heard  of  her. 

(d)  Two  years  after  amputation  of  the  left  breast  for  the  primary  disease, 
which  was  of  one  and  a-half  years'  duration,  recurrence  took  place  in  the 
mammary  region.  Half  a  year  later  this  was  freely  excised.  The  axillary 
glands  were  normal.  She  went  away  convalescent  thirty  days  later,  and 
has  not  since  been  heard  of.  The  recurrent  disease  was  a  small,  round- 
celled,  adeno-cystic  sarcoma. 

An  analytical  summary  of  my  seven  cases  of  non-cystic  adeno- 
sarcoma  gives  the  following  results  : 

A£-c. — The  earliest  age  at  which  the  disease  was  first  noticed 
was  22  years  ;  the  latest  49"8  years  ;  the  mean  age  36'4  years. 

The  numbers  for  each  quinquennial  period  were  as  follows  : — 
20  to  25  years  ...  ...  ...  ...     in    2  cases 

30  ))  35  5>       •••     •••     •••     •••  ))  2  „ 

45  ).  50  ),       •••     •••     •••     ••-   »  3  » 

Duration. — The  duration  of  the  disease  from  the  time  it  was 
first  noticed  until  the  patient  came  under  treatment  was  as 
follows  : — The  shortest  period,  6  weeks  ;  the  longest,  4  years  ; 
the  average,  I4"2  months. 

Civil  State,  &c. — Married,  4  ;  single,  3.  Of  the  married  all 
were  fertile.  One  had  i  child,  one  3  children,  one  3  children  and 
4  miscarriages,  and  one  5  children. 

The  Side  Affected. — The  right  in  5,  the  left  in  2. 

The  Original  Site  of  the  Disease. — It  was  central  in  4,  and 
peripheral  in  3  (upper  and  axillary  segment  in  2,  upper  in  i). 
In  all,  the  first  obvious  manifestation  of  the  disease  was  a 
solitary  nodule. 

Previous  Injury  or  Disease  of  the  Breast. — None  in  any  case. 


STATISTICAL    SUMMARIES.  425 

In   one   case    the  outbreak  of  the  disease    took   place  during 
pregnancy. 

Family  History. — Of  7  cases  there  was  family  history  of 
cancer  in  i,  the  patient's  aunt  having  died  of  malignant  disease 
of  the  breast. 

State  on  Examination .—T\\q.  size  of  the  tumour  in  most  cases 
did  not  exceed  that  of  a  hen's  egg,  the  smallest  was  the  size  of 
a  haricot  bean,  the  largest  of  a  man's  head.  In  all  cases  the 
tumours  were  mobile;  there  was  no  instance  of  adhesion  either 
to  the  overlying  skin  or  to  the  subjacent  pectoral  muscle.  The 
nipple  was  obliterated  by  stretching  in  one  case  and  normal  in 
the  other  six.  Most  of  the  tumours  were  of  globular  shape, 
lobulated,  and  encapsuled.  In  two  cases  the  superficial  veins 
were  much  enlarged.  The  lymph  glands  of  the  axilla  were 
unaffected  in  every  case. 

Treatment  and  Result. — Of  seven  primary  cases,  in  five  the 
breast  was  removed,  together  with  the  tumour,  all  the  patients 
soon  recovered  ;  in  two  cases  the  tumour  alone  was  removed, 
both  recovered.  The  period  of  convalescence  was  from  seven  to 
fourteen  days     In  no  instance  was  the  axilla  touched. 

The  subsequent  history  of  four  of  the  above  cases  was  as 
follows  : — 

(i)  The  patient,  aged  49,  had  a  fibro-spindled-celled,  adeno-sarcomatous 
tumour  of  the  right  breast  of  large  size  .and  of  two  years'  growth.  The 
axillary  glands  were  unaffected.  The  breast  was  removed,  together  with 
the  tumour,  which  was  found  to  have  grown  from  the  posterior  part  of  the 
gland.  When  last  seen,  six  years  later,  this  patient  was  well,  and  free  from 
recurrence. 

(2)  The  patient,  aged  50,  had  a  sarcomatous  tumour,  the  size  of  a  hen's 
^'g'g.,  in  the  upper  and  axillary  part  of  her  right  breast.  The  axillary  glands 
were  normal.  The  tumour  was  excised.  It  possessed  a  distinct  capsule. 
When  last  heai'd  of  two  and  a-half  years  later  she  was  free  from  any  return 
of  the  disease. 

(3)  A  single  woman,  aged  '})l-,  with  a  spindle-celled  sarcomatous  tumour  at 
the  upper  and  outer  part  of  her  left  breast,  of  eight  months'  duration.  The 
axillary  glands  normal.  The  breast  was  extirpated  together  with  the  tumour. 
Two  years  afterwards  the  patient  again  came  under  observation,  with  a 
somewhat  similar  tumour  in  her  right  breast  of  one  year's  duration.  This 
breast  was,  therefore,  removed  together  with  the  tumour.  The  latter  proved 
to  be  of  the  same  structure  as  the  original  one  in  the  left  breast.     When  last 


426  SARCOMA    OF    THE    BREAST. 

heard  of  two  years  later  she  was  well,  and  free  from  any  return  of  the 
disease. 

(4)  In  this  case  the  patient  was  a  married  woman,  aged  24,  with  a  round- 
celled  sarcomatous  tumour  of  large  size  in  her  right  breast.  It  was  first 
noticed  twelve  months  previously,  during  the  latter  part  of  her  first 
pregnancy.  The  overlying  skin  and  the  axillary  glands  were  normal.  The 
tumour  was  removed,  as  well  as  the  breast.  Four  months  later  a  growth  of 
a  similar  natui^e  had  formed  in  her  left  breast,  and  the  axillary  glands  were 
slightly  enlarged.  This  breast  with  the  tumour  and  the  a.xillary  glands  was 
now  removed.  When  last  heard  of  two  years  after  the  second  operation, 
she  was  in  good  health,  and  without  any  I'eturn  of  the  disease. 


S     II . Adeno-Sarcoma 

Bearing  in  mind  the  foregoing  facts,  I  now  propose  to  pass 
in  review  the  chief  features  of  mammary  sarcomata.  At  the 
outset  I  may  as  well  state  that  the  usual  varieties  of  sarcomatous 
growths,  met  with  in  other  parts  of  the  body,  are  also  found  in 
the  breast.  The  immense  majority  of  these  neoplasms  consist 
mainly  of  round  or  spindle-celled  structures ;  and,  according  to 
my  observations,  it  is  commoner  to  find  a  mixture  of  these  two 
forms  than  either  of  them  separately.  Thus,  of  19  consecutive 
primary  cases,  in  7  round  and  spindle  cells  predominated,  in  6 
round  cells  (with  myxomatous  tissue  in  i),  in  5  spindle  cells, 
and  I  was  so-called  alveolar  sarcoma.  In  the  cases  analysed 
by  Gross,  spindle-celled  forms  were  by  far  the  most  numerous ; 
he  estimates  the  percentage  proportions  as — spindle-celled  68, 
round-celled  27,  and  myeloid  5. 

What  gives  a  certain  peculiarity  to  sarcomata  of  the  breast 
is  the  frequency  with  which  glandular  elements  are  incorporated 
in  their  structure.  Although  there  is  every  reason  to  believe 
that  this  admixture  makes  no  essential  difference  in  the  nature 
of  the  disease,  yet  it  often  causes  the  form  assumed  by  the 
neoplasm  to  be  strangely  modified,  through  the  development  of 
cysts  and  intra-cystic  growths. 

It  is  generally  agreed  that  adeno-sarcomata  of  the  breast  are 
of  much  commoner  occurrence  than  pure  sarcomata,  but  no  one, 
so  far  as  I  know,  has  furnished  precise  data.     According  to  my 


ADENO-SARCOMA.  427 

investigations,  the  proportion  is  about  80  per  cent,  of  the  forn:ier 
to  20  per  cent,  of  the  latter.  This  indicates  a  much  larger 
proportion  of  pure  sarcomata  than  has  hitherto  been  generally 
believed.  Leaving  the  latter  for  subsequeut  consideration,  in 
what  follows  I  propose  to  confine  my  remarks  to  the  adeno- 
sarcomata. 

As  in  mammary  cancer,  the  initial  lesion  in  these  growths 
generally  is  a  small,  hard,  solitary  nodule.  Of  the  17  primary 
cases  in  my  list,  in  only  one  did  the  first  obvious  manifesta- 
tion consist  of  two  distinct  nodules.  Of  156  cases,  Gross  found 
multiple  nodules  in  7  ;  in  one  of  these  there  were  4  nodules 
in  one  breast,  and  i  in  the  other.  The  question  of  the  origin  of 
mammary  sarcomata  from  non-malignant  neoplasms  I  have 
elsewhere  discussed.* 

In  women,  cancer  and  non-malignant  neoplasms  arise  more 
frequently  from  the  left  than  from  the  right  breast.  According 
to  Schuoler,  this  is  also  the  case  with  sarcoma,  for  of  35  cases, 
21  were  of  the  left  and  14  of  the  right  side.  Of  my  19  cases,  12 
were  of  the  right  gland  and  only  7  of  the  left.  Both  breasts  are 
occasionally  simultaneously  affected  :  this  happened  in  3  out  of 
Gross'  156  cases,  and  of  Schuoler's  40  cases,  4  were  double.  In 
a  case  reported  by  Delbarre^,  small  round-celled  mammary 
sarcoma  was  associated  with  similar  ovarian  disease. 

As  compared  with  cancer,  it  appears  that  sarcomata  arise 
less  frequently  from  the  peripheral  parts  of  the  gland  ;  for  of  17 
cases  in  my  list,  9  were  of  central  and  8  of  peripheral  origin  ;  of 
the  latter,  3  sprang  from  the  axillary  and  lower  segment  of  the 
gland,  2  from  its  axillary  and  upper  segment,  2  from  its  upper 
and  one  from  its  lower  segment.  Forbes^  mentions  a  case  in 
which  the  disease  originated  from  a  supernumerary  mammary 
sequestration. 

At   an    early  stage  of   the  disease  the  initial   proliferating 


*  Pp.  315-317. 

'  Bull  lie  la  Soc.  Anal.,  1870,  p.  TyT^I. 
"  Phil.  Med.  Neius,  March  5,  1892. 


428 


SARCOMA    OF    THE    BREAST. 


cellular  aggregate,  together  with  its  contained  glandular 
elements,  that  constitutes  the  germ  of  the  future  tumour 
becomes  separated  from  the  surrounding  structures  by  the 
differentiation  of  a  fibrous  capsule,  which  soon  completely 
isolates  it.  By  the  continuous  proliferation  and  differentiation 
of  these  cells  and  their  descendants,  as  in  the  normal  develop- 
ment, the  tumour  increases  in  size.  This  being  so,  there  must, 
of  course,  be  new  formation  of  glandular,  as  well  as  of  con- 
nective tissue  elements.  Another  consequence  of  this  mode 
of  development  is,  that  fatty  tissue  is  never  found  in  the  midst 
of  the  morbid  mass,  as  in  cancer,  in  which  a  capsule  does  not 
form.     As   the  tumour  increases  in    size,  it   pushes   aside   the 


Fu;.  59.— Adeno-Sarcoma  {Birkett). 
Breast  and  tumour  dissected  to  show  their  mutual  relations,    (a)  Site  of  nipple  ; 
(/i)  Mamma  ;  {c)  Ligainenlasuspetisoria  ;  (r/)  Tumour  and  its  capsule  ;  (t')  Small  cysts. 


surrounding  parts ;  and  where  these  hinder  its  progress,  they  are 
destroyed  by  pressure  atrophy.  The  form  ultimately  assumed 
by  the  new  growth  depends  much  upon  the  evolution  of  its 
glandular  elements.  When  these  remain  comparatively  un- 
altered, non-cystic  solid  tumours  of  no  great  size  result ;  but 
when  they  dilate  and  form  cysts,  large  tumours,  complicated 
with  intra-cystic  growths,  commonly  ensue.  According  to  my 
observations,  the  majority  of  mammary  adeno-sarcomata  are 
of  the  cystic  kind,  the  proportion  being  59  per  cent,  of  the 
former  to  41   per  cent,  of  the  latter. 


ADENO-SARCOMA. 


429 


These  tumours  are  abundantly  supplied  with  blood-vessels, 
which  are  often  not  only  unduly  numerous,  but  also  unduly 
larg-e  and  otherwise  malformed.  Most  of  them  may  be  re- 
garded as  imperfect  capillaries,  but  veins  are  also  numerous 
and  arteries  exist.  They  are  derived  by  ectasis  from  the 
pre-existing  vessels.  In  soft,  cellular  tumours,  the  vascular 
walls  being  very  thin  and  ill-supported,  readily  dilate  and 
even  rupture ;  whereas  in  the  hard,  fibroid  kinds,  these  struc- 
tures play  a  much  less  prominent  part.  Sarcomata  are  believed 
to  be  devoid  of  nerves  and  lymphatics. 

The  non-cystic  growths  usually  present  as  lobulated  encap- 
suled  solid  tumours,  of  ovoid  or  globular  shape,  varying  in  size 
from  a  walnut  to  a  hen's  &gg  (fig.  59).  On  section  their  appear- 
ance is  whitish,  fibroid,  or  fleshy-looking.     They  are  generally 


Fig.  60.  —Non-cystic  adeno-sarcoma  in  section.     Natural  size  {Astley  Cooper). 


of  firm  and  elastic  consistence,  rather  than  hard.  In  the  tougher 
varieties  fibrous  tissue  predominates ;  in  the  softer  kinds 
cellular  elements.  Interspersed  throughout  their  substance 
numerous  small  branched,  cleft-like  slits  can  be  seen  (fig.  60) ; 
these  are  the  included  glandular  structures,  in  connection  with 
which  minute  cysts  may  be  noticeable. 

Histological  examination  shows  that  such  tumours  consist 
mainly  of  fibro-cellular  tissue  in  which,  according  to  my  obser- 
vations, spindle  cells  usually  predominate.     The  slit-like  clefts 


430 


SARCOMA    OF    THE    BREAST, 


embedded  in  this  tissue  are  the  elongated  and  otherwise  altered 
ductal  structures,  lined  by  one  or  several  layers  of  sub-columnar 
cells.  Sometimes  the  lumina  of  these  structures  are  distended 
by  degenerating  cells,  and  fluid  accumulations.  Hardly  ever 
does  one  see  glandular  structures  of  this  kind  lined  by  flattened 
cells  similar  to  those  of  the  normal  acini. 


Fig.  6i. — Adeno-cystic  Sarcoma.     Clinical  view,  from  a  photograph. 

In  the  cj/s^ic  form  of  the  disease  large,  irregular,  globular 
tumours  are  met  with,  which  sometimes  attain  immense  size  (figs. 
6i  and  64).  They  are  markedly  lobulatcd,  and  their  various 
sub-divisions  are  irregularly  nodular.     Occasionally  they  acquire 


ADENO-SARCOMA, 


431 


a  pedunculated  form.    A  capsule  can  generally  be  made  out,  but 
in  tumours  of  large  size  it  is  often  thin  and  incomplete. 

The  appearances  on  section  vary  much,  according  as  the 
solid  or  cystic  constituents  predominate.  As  a  rule  there  is 
revealed  a  multilocular  structure,  with  which  is  associated  a 
variable  amount  of  irregularly  distributed,  moist,  whitish-grey 
fleshy  solid  substance.  The  loculi  are  usually  distended  with 
polypoid    ingrowths  and  a  variable  amount   of  fluid.     Of  the 


a 


Fig.  62. — The  Foregoing  Tumour  in  Section. 
{a)  Nipple.     {!>)  Capsule,     (c)  One  of  the  several  solid  sarcomatous  masses  com- 
prising the  peripheral  part  of  the  tumour.       (d)  The  central  fibroid  part.      {e)  Its 
cystic  portion,  with  intra-cystic  growths.     (/)  Remains  of  the  mammary  gland. 


cases  under  my  own  observation,  one  of  the  smallest  tumours 
presented  on  section  quite  a  solid  appearance.  It  was  only  after 
careful  examination,  that  it  was  seen  to  consist  of  numerous 
loculi  tightly  distended  with  solid  polypoid  ingrowths,  without 
any  associated  fluid  whatever.  The  sarcomatous  new  formation 
in  this  case  was  small,  round  and  spindle-celled  tissue. 


432  SARCOMA    OF    THE    BREAST. 

The  following  is  an  account  of  the  largest  tumour  of  the 
kind  that  has  come  under  my  notice  : — 

The  specimen  was  removed  from  the  right  breast  of  a  married  woman 
aged  57,  who,  two  years  previously,  after  a  strain  in  lifting,  first  noticed  two 
lumps  the  size  of  hazel  nuts  in  the  lower  part  of  the  breast.  One  year  later 
a  single  tumour  had  formed  there,  the  size  of  an  orange.  When  I  first  saw 
her  the  breast  was  occupied  by  a  projecting  irregularly  ovoid  tumour,  nearly 
as  large  as  a  man's  head  (fig.  6i).  The  overlying  skin  was  adherent, 
purplish,  and  marbled  by  large  veins  ;  but  the  tumour  was  freely  movable 
on  the  subjacent  parts.  Its  surface  presented  numerous  rounded,  lobular 
projections,  which  were  nodulated.  The  nipple  was  not  retracted.  Most  of 
the  mass  was  of  firm  elastic  consistence,  but  at  its  lower  part  fluctuation 
was  distinct.  There  was  a  single  slightly  enlarged  gland  in  the  axilla. 
The  breast  was  amputated  without  opening  the  axilla.  On  section,  the 
bulk  of  the  tumour  was  seen  to  be  composed  of  solid  substance,  con- 
tained within  a  thick  fibrous  capsule  (fig.  62).  Its  peripheral  part  con- 
sisted of  numerous  large,  whitish,  fleshy-looking  nodules,  except  below 
the  nipple,  where  there  was  an  encapsulated  multi-locular  structure  the 
size  of  a  hen's  egg,  the  loculi  of  which  were  full  of  softish,  gelatiniform, 
club-shaped  ingrowths.  The  central  part  of  the  growth  consisted  of  coarse, 
dense,  fibroid  tissue,  from  the  meshes  of  which  pale,  dirty  yellowish  fluid 
exuded.  On  histological  examination  of  the  peripheral  lobules,  which  com- 
prised the  bulk  of  the  tumour,  these  were  composed  of  small  round  and 
ovoid  celled  sarcomatous  tissue  ;  the  central  fibroid  part  consisted  of  white 
fibrous  tissue,  with  nuclei  unduly  numerous.  No  glandular  structures  were 
met  with  in  this  part  of  the  tumour.  The  intralocular  growths  con- 
sisted of  loose  oedematous  fibrous  tissue,  with  many  nuclei  ;  while  the 
epithelial  lining  had  completely  disappeared,  as  the  result  of  disintegra- 
tion. The  patient  completely  recovered  from  the  operation,  and  when  last 
heard  of  a  month  afterwards  she  was  in  good  health,  and  free  from  any 
return  of the  disease. 

I  have  lately  seen  a  similar  tumour  of  much  larger  dimen- 
sions. 

It  occurred  in  the  person  of  a  widow,  aged  55,  the  mother  of  several 
healthy  children.  A  huge,  rounded,  bossy  mass,  hung  from  the  right  mam- 
mary region,  reaching  as  low  as  the  iliac  crest.  Most  of  it  was  of  firm, 
elastic  consistence,  with  here  and  there  small  fluctuating  areas,  evidently 
due  to  cysts.  It  was  freely  movable  over  the  subjacent  parts,  and  none  of 
the  adjacent  lymph  glands  were  enlarged.  The  overlying  skin  was  adherent, 
marbled  with  large  veins,  and  purplish.  An  area  the  size  of  a  crown  piece, ' 
over  the  lowest  part  of  the  tumour,  was  in  a  state  of  slough  ;  and  extensive 
gangrene  here  seemed  imminent.  The  tumour  was  of  fifteen  years'  growth, 
but  until  sloughing  set  in  a  few  weeks  ago,  it  had  not  caused  her  much  pain. 
I  estimated  its  weight  as  about  20  lbs.  As  gangrene  was  evidently  impend- 
ing, I  advised  its  immediate  ablation.  This  the  patient  declined,  as  she  was 
persuaded  by  a  quack,  who  had  treated  her  for  some  years,  that  the  tumour  was 


ADENO-SARCOMA.  433 

coming  away  by  its  roots.  Extensive  gangrene  soon  set  in,  and  after  having 
endured  horrible  sufferings  for  some  months,  she  died  exhausted.  This  is  a 
case  that  by  operation  might  have  been  completely  cured,  but  unfortu- 
nately nothing  could  shake  this  poor  woman's  faith  in  the  ignorant  man 
into  whose  hands  she  had  fallen.  Such  a  combination  of  obstinacy  and 
ignorance  is  fortunately  rare. 

Among  the  constituent  elements  of  the  neoplastic  tissue, 
round  cells  generally  predominate ;  frequently  these  are  asso- 
ciated with  spindle  cells,  and  occasionally  the  latter  predomi- 
nate. Myeloid  cells  are  now  and  then  met  with.  Within 
sarcoma  cells  Paulowsky,''  Clarke,^'^  and  others  have  met  with 
rounded,  spore-like  bodies,  which  they  regard  as  parasitic 
protozoa. 

The  following  is  the  only  example  of  rhabdo-myo-sarcoma 
of  the  breast  known  to  me  : — 

In  an  ill-developed,  chlorotic  girl,  aged  i6,  with  a  large  adeno-cystic 
sarcoma  in  the  middle  of  the  left  breast,  of  nine  months'  duration,  Billroth'' 
found,  on  histological  examination  of  the  tumour  after  removal,  in  addition 
to  small  round-celled  sarcomatous  tissue,  numerous  spindle-like,  trans- 
versely-striated muscle  cells.  To  account  for  this  unique  phenomenon,  he 
thinks  either  that  we  must  admit  the  origin  of  these  cells  from  the  sarcoma 
cells,  or  that  we  must  ascribe  their  origin  to  germs  of  transversely-striated 
muscle  tissue  sequestrated  during  an  early  stage  of  development. 

In  addition  to  the  foregoing,  there  is  generally  found  a 
variable — but  considerable — amount  of  fibrous  intercellular 
substance,  which  is  often  aggregated  into  irregular  strands.  It 
is  said  to  differ  from  the  fibrous  stroma  of  the  normal  and 
cancerous  glands  in  that  it  is  devoid  of  elastic  fibres.  Irregular 
gelatinous  metaplasia  is  not  uncommon  ;  and  in  this  connection 
pseudo-cysts  sometimes  arise.  Both  cells  and  intercellular 
substance  are  prone  to  fatty  degeneration,  which  may  be  so 
extensive  as  to  retard  the  progress  of  the  disease  and  cause 
partial   regression.     Both   of  these   degenerative   changes   give 


^  Arch.  f.  path.  yi«a/.,  Bd.  cxxxiii.,  S.  464.  "  Ueber  parasitiire  Zeilen-schliisse 
in  sarcomatosen  Geweben." 

•°  "  Cancer,  Sarcoma,  and  other  Morbid  Growths  in  Relation  to  the  Sporozoa," 
1893- 

"  Deutsche  Chir.,  Lieflxi.,  S.  53. 

28 


434  SARCOMA    OF    THE    BREAST. 

rise  to  yellowish  discolouration,  and  sometimes  to  caseation. 
Hyaline  metamorphosis  of  the  stroma  has  also  been  noticed. 
Small  calcereous  deposits  may  be  met  with,  but  it  is  rare  to 
find  large  areas  thus  affected,  as  in  cases  recorded  by  Dubar,^^ 
Clarke,^^  and  others.  Very  exceptionally  osseous  and  cartila- 
ginous tissues  have  also  been  found  in  the  stroma,  as  in  cases 
recorded  by  Hacker,^*  Wagner,^^  Bowlby,^*'  Coats,^'"  Battle,^** 
Pilliet,^^  &c.  Unduly  numerous,  enlarged,  and  irregularly 
formed  blood  vessels  are  not  very  rare,  and  in  the  telangiectasic 
variety  they  predominate.  These  various  changes  have  little 
or  no  influence  on  the  course  of  the  disease.  Inflammation  and 
suppuration  may  also  occur. 

With  regard  to  the  included  glandular  structures,  at  an  early 
stage  their  cells  by  proliferation  become  unduly  numerous,  and 
as  the  result  of  their  morbid  activity  fluids  are  secreted,  which 
distend  their  lumina,  and  so  finally  convert  them  into  cysts. 
In  the  next  stage  irregular  processes  of  the  proliferating  peri- 
ductal sarcomatous  tissue  project  into  the  cysts,  and  finally  form 
intra-cystic  growths.  These  generally  take  the  form  of  nodular 
club-shaped  masses  (fig.  63)  which  sometimes  attain  great  size; 
but  quite  exceptionally  papillary  structures  are  produced. ^*^ 
Cysts  of  all  shapes  and  sizes  are  met  with.  Epithelial  cells 
of  columnar  type  line  their  walls  and  the  surface  of  the  intra- 
cystic  growths.  This  indicates  that  their  origin  is  from  the 
small  ducts  rather  than  from  the  acini.  These  lining  cells 
sometimes  completely  disappear  during  the  growth  of  the 
tumour  as  the  result  of  degenerative  changes  (fig.  6^) ;  at  other 
times  they  undergo  a  kind  of  corneous  transformation,  forming 


'2  TMse  dc  Paris,  1888. 

"  Lancet,  1890,  vol  i.,  p.  1,179. 

"  Archiv.f.  klin.  Chir.,  1882,  S.  614. 

''■  Arch.  f.  Heilkunde,  1861,  S.  275. 

"'   Trans.  Path.  .Soc.  Lond.,  1882,  p,  306. 

"  "  Manual  of  Pathology." 

'«   Trans.  Path.  Soc.  Lond.,  1886,  p.  473, 

'"  Bull,  de  la  Soc.  Anal.,  1890,  p.  552. 

*  Pilliet,  "  Cysto-sarcome  papillaire  du  sein,"  Hull,  de  la  Soc.  Anat.,  1893. 


ADPINO- SARCOMA. 


435 


little  pearls,  as  in  cases  signalised  by  Borchmeyer  and  Schmidt.-' 
In  addition  to  the  solid  incjrowths,  the  cysts  usually  contain  a 
highly  albuminous,  pale,  yellowish   fluid,  in   which  histological 


Fig.  63. — Histological  Section  of  Adeno-cystic  Sarcoma,  showing  intra- 
CYSTic  Growths  {Billroth). 

{a)  Cystic  cavity  nearly  filled  by  a  large  ingrowth,  but  denuded  of  its  epithelial 
investment. 

examination  reveals  numerous,  degenerating  epithelial  cells,  cor- 
puscles of  Gllige,  leucocytes,  &c.  Sometimes  the  contents  form 
a  granulo-fatty  magma,  like  cheese  or  butter,  as  in  the  "tumeurs 


Arch.f.  Cj'/K,  Bd.  xxiii.,  1S84,  S.  93. 


436 


SARCOMA    OF    THE    BREAST. 


butyreuses,"  described  by  Velpeau.^^  In  a  specimen  of  this 
disease,  removed  during  lactation,  Billroth^^  found  milk  in  the 
dilated  glandular  structures.  Occasionally  there  is  complete 
absence  of  any  fluid  contents,  the  solid  ingrowths  completely 
filling  the  cysts. 

The  rate  of  increase  of  these  neoplasms  is  very  variable,  and 
their  progress  is  often  irregular.     It  happens  in  a  certain  pro- 


FlG.  64. — An  enormous  adeno-cystic  sarcoma  (  Velpean). 

portion  of  cases  that  the  original  tumour  remains  small  and 
almost  stationary  for  a  long  period,  and  then  suddenly  increases 
rapidly  without  any  obvious  cause.  The  round-celled  varieties 
are  believed  to  progress  the  most  rapidly,  but  as  to  this  the  evi- 
dence is  by  no  means  definitive.  Marked  local  elevation  of 
temperature  not  unfrcqucntly  accompanies  this  rapid  increase, 
and  occasionally  pyrexia  (Steinbcrger).  The  size  attained  by 
growths  of  this  kind  is  often  very  considerable — in  fact,  cystic 
adeno-sarcomata  arc  among  the  most  bulky  of  mammary 
neoplasms.      Specimens  weighing  7,  12,   13,   14,  22,  26  pounds 


""^  '*  Traite  des  Maladies  du  Sein,"  p.  301  et  saj. 
■■=•■'  Arch.  f.  path.  Attai.,  Bd.  xviii.,  S.  68. 


ADENO-SARCOMA.  437 

and  upwards  have  been  met  with.  In  the  following  remarkable 
instance  by  Velpeau,^^  the  tumour  was  of  truly  colossal  propor- 
tions : — 

Mrs.  A.,  aged  54,  four  years  ago  first  noticed  a  tumour  in  her  right  breast 
which  in  the  course  of  three  years  attained  the  size  of  a  man's  two  fists,  and 
then  increased  rapidly  to  its  present  gigantic  size.  An  enormous  lobulated 
tumour  is  connected  with  the  right  breast,  the  overlying  skin  being  congested 
and  eroded  in  places  inferiorly,  and  marbled  by  numerous  large  veins  (fig.  64.) 
Some  parts  of  it  feel  solid,  others  cystic.  Its  largest  circumference,  120  cm. 
(over  44  inches)  ;  its  diameters,  36  cm.  (14I  inches)  by  30  cm.  (over  12 
inches).  On  tapping  it  two  litres  (over  I5  quarts)  of  fluid  were  evacuated. 
The  patient  was  weak  and  emaciated,  and  refused  to  have  it  removed. 
She  only  ceased  to  menstruate  at  52.  Death  subsequently  supervened 
from  marasmus.  After  death  the  tumour  weighed  20  kilos,  (over  44  lbs.). 
Nothing  is  said  as  to  the  state  of  the  axillary  glands,  nor  as  to  dissemination. 

In  cases  of  this  sort  the  nipple  may  be  more  or  less  effaced 
by  stretching,  but  it  is  hardly  ever  retracted.  The  superficial 
veins  are  enlarged.  It  often  happens,  when  the  tumours  project 
much,  that  the  overlying  skin  becomes  congested  and  adherent  ; 
ulceration  may  then  supervene,  followed  by  fungation  of  the 
growth  {fungus  hcematodes).  In  the  event  of  the  exposed 
capsule  rupturing,  the  intra-cystic  growths  may  also  fungate. 
Even  under  these  circumstances  the  skin  is  not  often  invaded 
by  the  disease. 

I  witnessed  the  following  instance  of  this  kind  in  1879  at  the 
Hopital  Necker,  Paris,  in  the  practice  of  Broca  : — 

A  rather  ill-nourished,  but  otherwise  healthy-looking  woman,  aged  55, 
the  mother  of  several  healthy  children,  was  admitted  with  a  purplish,  fungoid 
outgrowth,  the  size  of  a  hen's  egg,  growing  from  the  central  part  of  the  right 
breast,  rather  below  and  internal  to  the  nipple.  It  was  of  firm  and  elastic 
consistence,  its  centre  somewhat  depressed,  its  borders  swollen  and  everted, 
and  its  surface  granular,  discharging  thin,  sanious,  puriform  fluid.  The 
nipple  was  displaced  but  not  retracted.  The  tumour  was  mobile  on  the 
subjacent  parts,  but  slightly  adherent  to  the  ovei-lying  skin  in  the  immediate 
vicinity  of  the  fungus.  There  was  no  pain,  and  the  adjacent  glands  were 
normal.  The  patient  said  she  first  noticed  a  lump  in  her  breast  eighteen 
years  previously,  soon  after  having  suckled  her  first  child.  It  remained 
stationary  for  eight  years,  when,  having  increased  quickly,  it  burst  and 
discharged  some  fluid,  after  which  the  fungus  formed.     She  cut  it  off,  but  it 


Op.  cit. 


43^  SARCOMA    OF    THE    BREAST. 

soon  formed  afresh.  The  breast  was  excised  together  with  the  tumour.  On 
examination  after  removal  the  latter  was  of  denser  structure  than  anti- 
cipated. Section  revealed  a  glistening,  whitish-yellow,  fibroid  surface, 
divided  into  lobes  by  irregular  fissures.  Numerous  small  cystic  cavities 
were  seen  filled  with  intra-cystic  growths.  Histologically,  the  latter  con- 
sisted of  loose,  fibro-cellular  tissue,  well  supplied  with  dilated  blood  vessels. 
The  solid  part  of  the  tumour  presented  numerous  elongated,  irregular,  ana- 
fractuous  cavities,  lined  by  cubical  epithelium,  mostly  in  a  single  layer. 
The  cysts  were  surrounded  by  abundant  fibro-spindle-celled  tissue. 

Obvious  local  disseminative  lesions  are  met  with  in  this 
disease  very  much  less  frequently  than  in  cancer,  and  the 
pectoral  muscles  are  rarely  invaded.  Nevertheless,  it  is  a  mis- 
take to  regard  the  presence  of  a  capsule  as  an  infallible  sign  of 
benignancy,  for,  as  these  growths  increase,  they  often  overpass 
the  limits  of  their  capsules  and  invade  the  adjacent  parts.  Even 
when  the  capsule  remains  intact,  and  there  is  no  obvious  invasion 
of  the  surrounding  structures,  careful  histological  examination, 
nevertheless,  often  reveals  tumour  eleinents  spreading  out  far 
from  the  main  tumour.  This  insidious  advance  of  the  disease 
takes  place  along  the  walls  of  the  blood  vessels — arteries  and 
veins — and  their  adventitia,  which  may  often  be  found  infiltrated 
with  sarcomatous  tissue.  As  Virchow,-''  with  his  usual  perspi- 
cacity has  pointed  out,  growths  of  this  kind  are  surrounded  by  a 
zone  of  latent  infection  which  usually  extends  far  beyond  their 
immediate  limits. 

The  opinions  that  have  been  entertained  by  competent  ob- 
servers, during  the  last  half  century,  as  to  the  benignancy 
or  malignancy  of  mammary  adeno-sarcomata,  have  been  very 
varied.  It  is  now,  however,  generally  recognised  that  all  neo- 
plasms of  this  kind  arc  of  a  more  or  less  malignant  nature.  The 
comparative  rarity  of  dissemination  in  the  axillary  glands  is  one  of 
their  most  striking  clinical  features,  in  which  they  differ  markedly 
from  cancer.  I  am,  however,  inclined  to  think  that  this  relative 
immunity  from  lymph  gland  dissemination  has  been  over- 
estimated, for  of  24  adeno-sarcomata  in  my  list,  there  were  two 
instances  of  it.     For  abstracts  of  these  cases  I  must  refer  the 


-'  La  Pathologic  des  Tuineurs,  t.  ii.,  p.  261. 


ADENO-SARCOMA.  439 

reader  to  the  foregoing  analytical  summaries.  It  is,  however, 
only  the  round-celled  variety  of  the  disease  that  thus  occasionally 
disseminates  in  the  glands.  In  two  other  instances  the  glandular 
enlargement  noticeable  was  only  hyperplastic. 

As  to  whether  these  growths  originate  general  disseminative 
lesions,  very  different  opinions  have  been  held.  Virchow-*^  was 
the  first  who  showed  conclusively  that  most  varieties  have  this 
power.  He  instanced  a  case  in  which  the  liver,  lungs,  medias- 
tina,  ribs,  vertebrae,  pelvic  bones,  dura  mater  and  sphenoid  were 
thus  implicated.  The  correctness  of  Virchow's  observations  has 
been  fully  borne  out  by  subsequent  investigations.  Of  91  cases 
tabulated  by  Gross,^'^  there  were  metastases  in  17,  or  in  i8"68 
pei'  cent.  ;  and  Schuoler  met  with  metastases  in  12*4  per  cent. 
In  Gross'  cases  the  secondary  lesions  were  situated  as  follows  : — 
Lungs  in  10  cases,  liver  in  4,  brain  in  3,  and  one  each  in  the  dura 
mater,  retro-peritoneal  glands,  mediastinum,  pleura,  heart,  kidney, 
muscles  and  bones.  Gross  believes  that  metastases  are  really  of 
more  frequent  occurrence  than  the  above  figures  indicate. 

Since  these  lesions  arise  in  the  absence  of  secondary  affec- 
tion of  the  lymph  system,  their  germs  evidently  enter  the  blood 
directly,  in  the  vicinity  of  the  primary  disease,  whence  they  are 
transported  by  the  circulation  to  the  localities  where  they  finally 
develop  into  fresh  tumours.  The  secondary  growths  differ  from 
the  primary  ones  in  being  devoid  of  glandular  elements,  which 
are  thus  shown  not  to  be  an  essential  part  of  the  disease.  Me- 
tastases have  not  been  signalised  in  connection  with  the  myeloid 
form,  and  only  exceptionally  does  this  variety  cause  dissemina- 
tion in  the  axillary  glands. 

All  the  varieties  of  mammary  adeno-sarcomata  frequently 
recur  locally  after  removal.  Under  these  circumstances  the 
recurrent  growths  usually  contain  no  glandular  elements.  This 
was  the  case  in  7  of  the  9  recurrences  in  my  list.  When 
glandular  elements  are   present   in  the  latter,  it   means   either 

-'^  op.  cit.,  t.  ii.,  p.  360. 

-'  "Am.  Syst.  Gyn.,"  vol.  li.,  p.  247. 


440  SARCOMA    OF    THE    BREAST, 

that  the  primary  disease  has  been  imperfectly  extirpated,  or 
that  fragments  of  the  gland  have  been  left  behind,  which  have 
subsequently  taken  on  the  same  form  of  morbid  activity. 

Of  14  primary  adeno-sarcomata  in  my  list  in  which  the 
breast  had  been  removed  together  with  the  disease,  in  3  local 
recurrence  was  known  to  have  occurred,  or  in  2r4  per  cent. 
Schuoler  met  with  it  in  25  per  cent,  of  his  cases,  and  Gross  in 
58  per  cent.  In  one  of  the  above-mentioned  cases  in  my  list 
the  patient  was  well  and  free  from  any  return  of  the  disease  six 
years  after  the  operation.  In  another  case  the  patient  was  well 
and  free  from  recurrence  two  and  a-half  years  after  excision  of 
the  first  local  recurrent  growth.  In  3  other  of  my  cases  the 
sarcomatous  tumour  was  simply  excised,  without  removing  the 
breast ;  in  one  of  these  there  was  local  recurrence  two  years 
later,  and  in  the  other  the  patient  was  free  from  any  return  of 
the  disease  when  last  heard  of,  two  and  a-half  years  after  the 
operation.  In  the  3  locally  recurrent  cases  of  my  list,  the  disease 
reappeared  three  months,  nine  months,  and  two  years  respec- 
tively after  the  last  operation. 

According  to  Gross,  more  than  half  of  the  local  recurrences 
(57'5  ps^  cent.)  take  place  during  the  first  six  months  after  the 
operation  ;  while  after  the  first  year  only  28'8  per  cent,  of  recur- 
rences arise,  and  after  the  first  two  years  but  8*8  per  cent.  Hence 
the  longer  the  period  of  immunity  after  operation  the  more 
favourable  the  prognosis.  In  his  cases  the  average  date  of  local 
recurrence  was  I0"5  months  after  operation;  the  latest  date  was 
four  years.  Return  of  the  disease  locally  after  operation  is,  how- 
ever, sometimes  met  with  at  a  much  later  period  than  this. 
Pean^^  has  recorded  an  instance  in  which,  twenty-five  years  after 
amputation  of  the  breast  for  adeno-cystic  fibro-sarcoma,  a  large 
tumour  of  similar  nature  formed  at  the  primary  seat,  in  a  woman 
aged  62.  The  number  of  recurrences  is  sometimes  very  great ; 
as  many  as  4,  5,  6,  7,  12  and  upwards  have  been  witnessed.  In 
the  following  remarkable  case  by  Gross,  the  patient  underwent 


Lefons  de  Clin.  Chir.,  1892,  p.  960. 


ADENO-SARCOMA. 


44' 


22  operations,  and    54   recurrent  tumours  were  removed  in   the 
short  space  of  four  years  : — 

A  single  woman,  aged  44,  with  a  small  tumour  in  her  left  breast  of  about 
seven  months'  duration.  It  was  excised,  and  found  to  be  a  small,  spindle- 
celled  sarcoma.  During  the  next  sixteen  months  two  similar  operations 
were  done  ;  and  then  a  fourth  recurrence,  together  with  the  entire  breast, 
was  extirpated.  Three  and  a-half  months  later  further  recurrent  disease  was 
excised,  and  soon  afterwards  several  other  operations  were  reciuired.  During 
the  last  two  years  sixteen  similar  operations  were  performed,  and  large 
portions  of  the  pectoral  and  intercostal  muscles  were  excised.  The  recurrent 
growths  varied  in  size  from  an  almond  to  a  hen's  egg  ;  they  appeared  at  or 
near  the  cicatrices  and  quickly  assumed  a  fungating  aspect.  There  was  no 
enlargement  of  the  adjacent  lymph  glands,  and  the  patient's  general  health 
throughout  was  good.  When  last  heard  of,  ten  years  and  nine  months  after 
the  last  operation,  she  was  in  perfect  health,  and  free  from  any  return  of  the 
disease. 

According  to  the  same  author,  the  period  of  immunity  from 
recurrence  is  longer  for  spindle  than  for  round-celled  forms,  and 
it  is  longest  of  all  for  the  myeloid  variety.  The  recurrence  of 
adeno-cystic  growths  sets  in,  as  a  rule,  about  eight  months  after 
operation,  whereas  the  period  for  the  non-cystic  form  is  about 
thirteen  months. 

Of  91  primary  operated  mammary  sarcomata  in  Gross'  list, 
32  were  found  to  have  survived  and  to  be  free  from  recurrence 
for  periods  ranging  from  i  month  to  10  years  and  9  months,  the 
average  period  being  rather  over  49  months.  The  mean  dura- 
tion of  the  life  of  these  patients,  since  the  onset  of  the  disease, 
had  been  nearly  10  years.  The  freedom  from  recurrence  had 
lasted — 


rom  I 

to  12  mon 

ths... 

...    in 

4 

cases 

„      I 

„  2  years 

4 

1 

55      3            5) 

7 

))      3 

„  4      5, 

5 

,       4 

55  5     55 

5 

„      7 

55      10      5, 

4 

„    10 

„   10  ,,  and  9  months 

3 

The  total  duration  of  life,  in  operated  cases,  Gross  has  found  to 
be  81  months  ;  90  months  for  spindle-celled  forms,  54  for  round- 
celled  ones,  and  108  months  for  the  myeloid  kind. 

In  2  of  the  cases  in  my  list  it  will  be  observed  that,  after 


442  SARCOMA    OF    THE    BREAST. 

removal  of  the  primarily  affected  breast,  there  was  recrudescence 
of  the  disease  in  the  opposite  breast,  and  none  at  the  primary 
seat.  In  both  of  these  cases  the  second  attack  appeared  to  be 
of  spontaneous  origin,  rather  than  the  result  of  local  dissemina- 
tion or  metastasis.  For  further  details  of  these  cases  the  reader 
is  referred  to  the  foregoing  analyses. 

With  regard  to  the  data  relating  to  the  influence  of  sex,  age, 
civil  state,  occupation,  pregnancy,  catamenial  function,  previous 
injury  or  disease  of  the  breast,  previous  health,  family  history, 
&c.,  little  need  be  added  to  what  has  been  set  forth  in  my 
analyses. 

According  to  Gross,  the  disease  may  supervene  as  early  as 
9  years,  and  as  late  as  75,  the  average  age  of  his  cases  being 
40'6.  Only  27  per  cent,  of  them  supervened  before  the  sixteenth 
year,  while  52  per  cent  supervened  after  the  fortieth  year.  The 
average  age  at  onset  for  the  spindle-celled  forms  was  36,  for  the 
myeloid  47,  and  for  the  round-celled  48  years.  Twelve  per 
cent,  of  the  spindle-celled  cases  commenced  before  16. 

The  data  relating  to  family  history  and  heredity  are  on  the 
whole  similar  to  those  ascertained  by  me  to  hold  for  cancer,  and 
similar  inferences  may  be  drawn  from  them.^^  There  is  in  the 
Middlesex  Hospital  Museum^°  a  specimen  of  sarcoma  of  the 
breast,  removed  from  a  lady  whose  two  sisters  had  similar 
disease,  also  of  the  breast ;  and  Paget^^  cites  the  case  of  a  lady, 
the  victim  of  hard  cancer  of  the  breast  (other  members  of  her 
family  were  believed  also  to  have  died  of  cancer),  whose  three 
daughters  all  developed  adeno-sarcoma  of  the  breast. 

Just  so  is  it  with  regard  to  the  etiological  significance  of 
previous  local  injury  or  disease,  civil  state,  pregnancy,  &c. ;  the 
conclusion  from  the  data  being,  that  in  the  vast  majority  of  cases 
the  outbreak  of  the  disease  is  entirely  spontaneous,  and  not 
traceable  to  the  immediate  action  of  any  appreciable  extrinsic 
cause  whatever. 


-"  Q.v.  Ch.  X.,  §  iv.  ♦ 

^°  Nos.  2,079  =i"d  2,093,  Path.  Catalogue,  pp.  257  and  259. 
^'  "  Lectures  on  Surgic.il  Palhulogy,"  vol.  ii.,  1854,  p.  260. 


adp:no-sakcoma.  443 

In  making  the  differential  diagnosis  the  following  are  some 
of  the  chief  clinical  features  to  be  borne  in  mind  : — 

The  disease  usually  presents  as  a  rather  large,  rounded  or 
ovoid,  lobulated,  bossy  tumour.  It  feels  firm  and  elastic,  except 
where  cysts  prevail.  It  is  distinctly  circumscribed,  and  freely 
movable  over  the  subjacent  parts  and  under  the  overlying  skin. 
Occasionally,  hov/ever,  the  latter  becomes  adherent,  discoloured, 
and  ulcerated,  and  the  tumour  may  fungate.  The  subcutaneous 
veins  are  generally  obviously  enlarged.  The  nipple  may  be 
flattened  by  stretching,  but  its  retraction  is  never  caused  by  the 
disease.  Serous  or  sero-sanious  discharge  from  the  nipple  is 
exceptionally  seen — i  in  9-5  cases,  according  to  Gross,  There 
is  no  enlargement  of  the  adjacent  lymph  glands.  Satellite 
secondary  nodules  in  the  parts  adjacent  to  the  main  tumour  are 
but  rarely  met  with.  A  certain  amount  of  pain  and  tenderness 
is  experienced  in  many  cases,  but  these  sensations  present  no 
special  characteristics.  The  disease  generally  runs  a  chronic 
course. 

With  regard  to  the  treatment,  it  follows  from  what  has  been 
stated,  that  the  whole  breast,  together  with  the  tumour  and  the 
overlying  skin,  should  be  freely  removed  in  every  case  at  the 
earliest  possible  date.  Unless  the  tumour  is  situated  altogether 
on  the  anterior  aspect  of  the  gland,  the  fibrous  sheath  of  the 
pectoral  muscle  should  also  be  removed  with  it.  Simple 
enucleation  of  the  tumour  must  be  condemned  as  an  unscientific 
procedure.  After  extirpation  of  the  diseased  part  it  is  a  good 
practice  to  wash  the  wound  with  strong  solution  of  chloride  of 
zinc  (20  to  40  gr,  ad.  i  oz.).  In  doing  the  operation  care  must 
be  taken  to  completely  remove  the  axillary  mammary  processes. 
When  enlarged  lymph  glands  are  present  the  axilla  should  be 
cleared,  just  as  is  done  for  cancer. 

As  to  the  mortality  after  the  operation,  of  the  14  primary 
extirpations  in  my  list  (the  axilla  having  been  cleared  in  one)  all 
recovered. 

With  regard  to  the  after  results  but  little  need  be  added  to 
what  has  already  been  stated.     From  this  it  will  be  gathered 


444  SARCOMA    OF    THE    BREAST. 

that  recurrences  rarely  supervene  later  than  four  years  after  the 
primary  operation.  Those,  therefore,  who  survive  free  from 
return  of  the  disease  after  this  period  may  be  regarded  as  cured. 
Of  Gross'  91  operated  cases,  12  fulfilled  this  requirement,  or 
1 3" 1 8  per  cent.  Recurrent  growths,  when  operable,  should  be 
freely  excised  as  soon  as  noticed.  This  practice  not  only  pro- 
longs life,  but  in  many  cases,  after  repeated  operations,  it  has 
at  length  resulted  in  permanent  cure. 


0     111. Pure  Sarcoma. 

In  the  absence  of  the  requisite  data,  it  is  impossible  to  write 
the  history  of  the  pure  sarcomata  of  the  breast ;  but  from  such 
information  as  is  forthcoming,  it  may  with  tolerable  certainty 
be  inferred,  that  the  main  features  of  this  disease  are  very  similar 
to  those  met  with  in  the  corresponding  varieties  of  adeno- 
sarcoma.  Pure  sarcomata  seldom  originate  such  large  tumours 
as  the  adenoid  variety,  moreover,  the  former  are  generally 
less  lobulated  and  bossy  than  the  latter.  Both  varieties  are 
usually  encapsuled  ;  and  very  rarely  does  either  disseminate 
in  the  adjacent  lymph  glands.  Stilling^-  has  met  with  a  pure 
sarcoma  that  contained  cartilaginous  and  osseous  nodules.  As 
examples  of  the  ordinary  varieties  of  pure  sarcoma,  the  follow- 
ing cases  are  instructive  ; — 

(i)  ■"  An  emaciated  woman,  aged  50,  came  under  Morton's  notice,  with  a 
tumour  the  size  of  a  child's  head  occupying  her  left  breast.  She  said  it  began 
nine  months  previously,  one  month  after  having  had  a  blow  on  the  breast. 
The  tumour  was  of  firm  consistence  and  bossed.  On  its  axillary  aspect 
were  two  nodules,  one  of  them  firm  and  the  other  quasi-fluid.  The  tumour 
was  freely  movable  over  the  pectoral  muscle.  The  skin  over  its  most  de- 
pendent part  was  red,  oedematous,  and  sloughing,  and  the  superficial  veins 
were  greatly  enlarged.  The  nipple  was  retracted.  In  the  axilla  was  a 
smooth  tumour  the  size  of  a  duck's  egg.  The  breast  was  amputated  and 
the  axilla  cleared.  On  section,  a  uniformly  whitish,  solid,  succulent  structure 
was  exposed,  devoid  of  cysts  and  clefts.  The  axillary  glands  were  invaded 
by  similar   growth.     Histologically,  it    proved  to    be  a  small,  round-celled 

^  Deutsche  Zeitschr.  f.  Chir.,  Bd.  xv.,  1881,  S.  247. 
**  Trans.  Path.  Soc.  Land.,  1893,  p.  126. 


PURE    SARCOMA.  445 

sarcoma,  with  some  spindle  cells  and  fibrous  tissue  intermixed,  but  no 
glandular  structures.  Death  occurred  a  month  after  the  operation,  from  an 
acute  outbreak  of  the  disease  in  the  glands  at  the  root  of  the  neck,  Sec.  On 
post-7norte}n  examination  there  were  no  metatases. 

(2)  ^'  A  multipara,  aged  44,  ten  years  ago  first  noticed  a  tumour  the  size 
of  a  pea  in  the  right  breast,  just  above  and  external  to  the  nipple.  During 
the  first  eight  years  of  its  existence  it  made  hardly  any  perceptible  progress. 
Since  then  it  has  increased  rapidly.  On  examination,  Mouchet  found  the 
breast  occupied  by  a  tumour  the  size  of  an  orange,  over  which  the  skin  was 
reddish,  and  at  one  place  eroded.  It  was  freely  movable  over  the  subjacent 
parts,  and  the  nipple  was  normal.  Her  general  health  was  good.  There 
were  no  enlarged  axillary  glands.  The  breast  was  extirpated,  and  the  axilla 
cleared.  On  section,  a  firm,  solid  tumour,  of  uniform  texture  and  whitjsh- 
grey  colour  ;  no  juice  exuded.  Histologically,  fibro-spijidle-celled  sarcoma 
with  complete  absence  of  glandular  structures. 

(3)  '•'  A  childless  widow,  aged  53,  two  or  three  months  before  coming 
under  observation,  first  noticed  a  small  lump  in  her  left  breast.  Her  general 
health  was  excellent,  but  a  sister  had  died  of  cancer  of  the  breast.  On  ex- 
amination, in  the  sternal  segment  of  the  gland,  on  a  level  with  the  nipple, 
was  a  rounded,  well-defined,  slightly  nodular  tumour,  one  and  a-half  inches  in 
diameter.  It  felt  moderately  firm,  was  mobile  under  the  overlying  skin,  and 
over  the  subjacent  pectoral  muscle,  and  the  nipple  was  not  retracted.  There 
was  a  single,  slightly  enlarged  gland  in  the  axilla.  An  exploratory  incision 
was  made  into  the  tumour,  when  some  soft  pinkish-white  granulation-like 
tissue  extruded.  This  was  found  to  consist  of  round  and  spindle  cells,  so 
that  the  whole  breast  was  extirpated,  together  with  the  overlying  skin.  The 
patient  made  a  quick  recovery.  On  examination  of  the  tumour  after  re- 
moval, its  superficial  part  was  surrounded  by  a  dense  fibrous  capsule,  which 
at  its  deep  aspect,  was  incomplete.  The  neoplastic  tissue  consisted  of 
rounded  and  ovoid  cells,  with  a  few  small  spindle  cells,  embedded  in  a 
granular  matrix.  The  spindle  cells  were  in  places  arranged  in  irregular 
fasciculi.  The  tumour  contained  numerous  blood  vessels,  surrounded  by 
spindle  cells.  It  was  solid  throughout.  The  sarcoma  cells  contained  laroe 
nuclei,  and  often  more  than  a  simple  nucleolus.  No  glandular  structures 
could  be  found  in  any  part  of  the  tumour.  Numerous  minute  cysts  were 
found  in  the  breast,  which  was  otherwise  normal. 

(4)  A  plethoric  multipara,  aged  53,  about  eight  years  ago  noticed  a 
small,  hard  lump  in  her  right  breast,  which,  during  the  last  two  years,  had 
caused  her  much  pain.  On  examination  the  right  breast  was  found  to  be 
occupied  by  a  rounded  tumour,  five  inches  in  diameter.  It  felt  firm  and 
elastic,  except  over  its  most  projecting  part,  where  it  was  softer  and  quasi- 
fluctuating.  Over  this  area  the  skin  was  purplish,  but  not  adherent.  The 
superficial  veins  were  enlarged.  The  nipple  was  flattened  by  stretching-,  but 
not   retracted.     The  tumour  was  mobile  under  the  skin  and  over  the  sub- 


"  Mouchet,  Bull,  de  la  Soc.  AnaL,  No.  21,  1S93,  P-  545- 

''  This  and  the  following  case  are  from  the  Univ.  Coll.  Hasp.  Re/>.  for  1S89. 


446  SARCOMA    OF    THE    BREAST. 

jacent  parts.  There  was  no  enlargement  of  the  axillary  glands.  The  whole 
breast  was  excised,  and  she  left,  convalescent,  twenty  days  later.  When  last 
heard  of,  ten  months  later,  she  was  well  and  free  from  recurrence.  The 
tumour  was  found  to  be  lobulated  and  encapsuled,  but  in  some  parts  the 
capsule  was  thin  and  ill-denned.  On  section  it  presented  a  pinkish-white 
aspect,  and  was  solid  throughout.  Its  peripheral  part  was  of  soft,  succulent 
nature,  while  more  centrally  a  firmer  structure  prevailed,  in  which  there  was 
a  small  calcareous  deposit.  Histologically,  the  growth  consisted  of  sinall 
round  and  spitidle  cells  embedded  in  an  abundant  fibrillar  matrix,  which 
contained  numerous  small  blood  vessels.  No  glandular  structures  were 
present. 

(5)  Chretien*'  has  published  an  account  of  a  pure  spindle-celled  sarcoma, 
that  developed  with  great  rapidity  in  the  breast  of  a  woman  during  lactation, 
and  in  the  course  of  seven  months  attained  the  weight  of  over  two  pounds. 

The  following  remarkable  case  of  acute  sarcoma  of  both 
breasts  is  from  Billroth'.s"  practice  : — 

An  artisan's  wife,  aged  31,  the  mother  of  two  children,  when  about  three 
months  gone  in  her  third  pregnancy,  noticed  a  rapidly  increasing  swelling 
in  her  left  breast.  There  was  some  slight  oozing  from  the  nipple,  but  no 
pain.  As  the  swelling  increased,  the  patient  got  progressively  weaker  and 
more  emaciated.  When  Billroth  first  saw  her,  a  few  months  later,  the  left 
mamma  was  occupied  by  a  tumour  the  size  of  a  man's  head,  which  felt  firm 
and  elastic.  The  overlying  skin  was  oedematous,  but  the  mass  was  freely 
movable  on  the  subjacent  parts.  There  was  no  enlargement  of  the  adjacent 
lymph  glands.  In  the  right  breast  several  hard  nodules  could  be  felt. 
Thinking  the  spread  of  the  disease  might  be  checked  if  delivery  were 
accomplished,  abortion  was  induced,  and  a  living  seven  months'  child  was 
born,  which  died  soon  afterwards,  but  presented  nothing  abnormal.  Pyrexia 
followed,  with  cough,  anorexia  and  marasmus  ;  and  she  died  thus  one  month 
after  delivery,  no  milk  secretion  having  taken  place.  There  was  no  necropsy. 
The  right  breast  had  in  the  meantime  grown  as  big  as  the  left,  whiqli,  in  its 
general  features,  it  resembled.  An  incision  was  made  into  each  breast,  and 
pieces  were  removed  for  histological  examination.  The  tumour,  on  section, 
presented  a  whitish-yellow,  succulent  aspect,  exuding  a  milky  fluid  on  pres- 
sure. Histological  examination  revealed  a  small,  round-celled,  lympho- 
sarcomatous  structure,  which  contained  no  glandular  elements. 

5^    IV, So-Called  Alveolar  Sarcoma. 

Under  the  name  of  alveolar  sarcoma,  plexiform  angio-sar- 
coma,  endothelioma,  &c.,  certain  rare  form.'  of  mammary 
neoplastic  disease  have  been  described,  in  which  the  glandular 


*>  Bull,  de  la  Soc.  Avat.,  1891,  p.  367. 
'^'•Deutsche  Chir.,  Lief,  xli.,  S.  27. 


SO-CALLED    ALVEOLAR    SARCOMA.  447 

elements  do  not  participate.  According  to  recent  investigations 
these  growths  arise  from  the  endothelial  cells  of  the  adventitia, 
or  of  the  lymph  spaces.  If  we  accept  this  view  of  their  origin, 
they  should  be  classed  with  the  cancers,  for  embryological 
researches  have  shown,  that  the  endothelium  is  a  derivative  of 
the  archiblast  and  not  of  the  parablast,  to  which  its  origin  has 
hitherto  generally  been  ascribed. 

There  are  many  facts  in  the  morphology  and  clinical  history 
of  the  disease,  that  are  best  explained  from  this  standpoint. 
Schmidt^^  has  studied  these  neoplasms  as  they  occur  in  the 
breast.  He  describes  their  gross  morphological  features  as 
being  very  similar  to  those  of  the  adeno  -  sarcomata.  They 
differ  from  the  latter,  however,  in  that  the  overlying  skin  is 
more  frequently  adherent ;  moreover,  they  much  more  frequently 
disseminate  in  the  adjacent  lymph  glands  and  in  the  system 
generally.  Tn  these  respects  they  resemble  the  cancers  ;  but 
unlike  the  latter,  they  generally  have  a  pseudo-capsule,  they 
do  not  cause  retraction  of  the  nipple,  neither  do  they  entail 
cachectic  symptoms. 

With  regard  to  the  relative  frequency  of  lymph  gland  dis- 
semination, Gross  says  it  is  met  with  in  over  66  per  cent,  of  all 
cases ;  whereas  Schmidt  describes  it  as  being  rare.  Both  are, 
however,  agreed  as  to  the  frequency  of  metastases.  These  have 
been  found  in  the  liver,  lungs,  bones,  spleen,  kidneys  and  omen- 
tum. Local  recurrences  after  removal  are  of  rapid  formation, 
and  of  very  frequent  occurrence. 

On  section  a  reddish-yellow  structure  is  displayed,  in  which 
imperfect  alveolation  can  often  be  made  out  with  the  naked  eye, 
certain  of  the  septa  generally  being  perfectly  obvious.  Histo- 
logical examination  reveals  an  alveolar  formation,  the  walls  of 
which  consist  of  strands  of  sarcoma  cells  grouped  around  fine 
capillary  blood  vessels.  Within  the  alveoli  are  large  ovoid  or 
rounded,  nucleated,  epitheloid  cells,  which  are  derived  b}^  pro- 
liferation from  the  cells  lining  the  dilated  lymph  spaces  within 

■'''  Jfr/i.  f.  klin.  C/iir.,  Bd.  xxxvi.,  1S87,  S.  421. 


448 


SARCOMA    OF    THE    BREAST. 


which  they  lie  (fig.  65),  As  the  intra-alveolar  cells  increase, 
they  often  cause  by  their  pressure  obliteration  of  the  surround- 
ing blood  vessels,  and  so  hyaline  or  myxomatous  degeneration 
of  the  corresponding  part  of  the  neoplasm,  which  sometimes 
results  in  cystic  formation. 

Inasmuch  as  these  growths  are  highly  malignant,  they  should 
be  freely  extirpated,  as  soon  as  possible,  together  with  the  breast 
and  overlying  skin  ;  and  the  axilla  should  be  cleared  as  well  in 
every  case.  The  following  is  a  good  example  from  the  Uni- 
versity College  Hospital  Reports?'^ 


Fic;.  65. — Histological  section  of  alveolar  sarcoma,      x  400.     (Formad.) 


A  multipara,  aged  55,  with  a  tumour  in  her  left  bi'ast  the  size  and  shape 
of  a  fowl's  egg.  It  was  of  five  months'  duration.  A  single  enlarged  gland 
could  be  felt  in  the  axilla.  The  tumour  was  mobile,  and  neither  the  skin 
nor  the  adjacent  structures  were  obviously  invaded.     The  breast  was  ampu- 


For  1S85,  p.  124  ;  and  for  1SS7,  p.  1S4. 


SO-CALLED    ALVEOLAR    SARCOMA.  449 

tated  and  the  axilla  cleared.  She  .vas  convalescent  about  a  month  later. 
The  tumoLu-  was  firm  in  consistence,  its  cut  surface  was  intersected  by 
fibroid  bands,  and  in  its  substance  were  embedded  numerous  minute  cysts. 
On  histological  examination  the  tumour  structures  were  found  to  be  much 
degenerated,  but  at  its  periphery  the  alveolar  arrangement  was  clearly 
manifest.  The  alveolar  walls  consisted  of  embryonic  round  and  spindle- 
celled  tissue,  including  ovoid  spaces  containing  epithelioid  cells.  Similar 
disease  had  invaded  the  enlarged  axillary  gland.  About  two  years  later  this 
patient  again  came  under  observation  with  recurrence  in  the  mammary 
region  and  axilla  ;  and  she  died  soon  afterwards  with  metastases  in  the 
vault  of  the  skull  (which  had  perforated  the  bones),  brain,  right  femur,  left 
humerus,  sternum,  both  lungs,  liver,  and  both  kidneys. 

Billroth^^has  reported  the  following  instance  of  a  rare  variety 
of  the  disease — myeloid  alveolar  sarcoma. 

A  multipara,  aged  42,  with  a  tumour  the  size  of  a  fist — of  a  few  months' 
duration — in  her  right  breast.  It  was  nodular,  circumscribed,  mobile  and 
felt  tough.  The  axillary  glands  were  unaffected.  On  examination,  after 
extirpation  of  the  breast,  the  tumour  was  found  to  be  encapsuled.  On 
section  it  presented  a  greyish-red,  lobulated  aspect,  and  on  pressure  pulpy 
substance  exuded  from  its  quasi-alveolar  structure.  Histologically  there 
was  revealed  an  alveolar  arrangement,  with  here  and  there  small  areas  of 
cystoid  softening.  The  alveolar  structure  consisted  of  fibro-spindle-celled 
tissue,  and  its  meshes  were  packed  with  numerous  large  cells,  many  of 
them  containing  from  five  to  ten  nuclei.  About  three  months  later  she 
again  came  under  treatment  with  development  of  the  disease  in  the  axilla. 
This  was  dissected  out,  and  it  exactly  resembled  the  primary  neoplasm. 
Two  months  later  there  was  recurrence  in  the  mammary  scar.  This  was 
also  excised.  Four  months  later  she  again  came  under  treatment  with 
recurrence  in  the  axilla.  This  was  again  excised,  but  she  died  shortly 
afterwards  of  septic  disease  supervening  on  erysipelas.  The  necropsy 
revealed  no  metastases. 

Under  the  name  of  myeloid  carcinoma  similar  cases  have 
been  recorded  by  Snow^^  and  Farmakowsky."*- 

It  seems  to  me,  that  Phillips''^^  remarkable  case  of  "  multiple 

epithelioma,"  of  which  an  abstract  is  subjoined,  properly  belongs 

to  this  category. 

The  patient  was  a  single  woman,  aged  34,  who  two  years  previously  first 
noticed  a  small  subcutaneous  tumour  in  her  right  breast ;  and  about  two 
months  afterwards,  over  a  dozen  similar  tumours  appeared  beneath  the  skin 

^"  Deutsche  Chir.,  Lief,  xli.,  S.  58. 

"   Brit.  Med.  yournal,  vol.  i.,  p.  62,  1894 — "  Breast  Carcinoma  with  Myeloids." 

*'-  "  Ueber  Carcinoma  Mammje  niit  Riesenzellen,"  Bern,  1890. 

"  iV.Y.  Med.  Record,  June  10,  1893,  p.  639. 

29 


450  '  SARCOMA    OF    THE    BREAST, 

of  various  parts  of  the  trunk.  The  original  tumour  in  the  lireast  steadily 
increased  in  size.  There  was  no  obvious  atTection  of  the  adjacent  lymph 
glands.  Seven  months  later  sixty-four  of  these  small  tumours  were  counted. 
They  were  pretty  evenly,  and  somewhat  symmetrically  distributed  over  the 
scalp,  face,  neck,  trunk,  and  thighs,  but  only  a  few  very  small  ones  formed 
in  the  forearms  and  legs.  There  was  no  family  history  of  neoplasia.  When 
a  child  she  had  rheumatic  fever,  and  she  was  choreic  at  1 1  ;  and  until  a 
few  years  ago  she  suffered  much  from  rheumatic  pains,  especially  in  the 
knees  and  ankles.  A  year  later,  as  the  tumours  continued  to  increase  in 
size  and  numbers,  seven  of  the  largest  were  excised  ;  and  ten  days  later 
fifteen  more.  Most  of  these  soon  recurred  with  renewed  vigour.  During 
the  next  few  months  1 13  more  were  excised  ;  the  wounds  healed  rapidly  and 
m  many  instances  there  was  no  subsequent  recurrence.  The  largest  tumour 
removed  was  the  original  one  in  the  right  breast  ;  it  weighed  10  ounces.  In 
spite  of  this  heroic  treatment  new  growths  continually  formed,  so  that  25- 
years  after  the  appearance  of  the  original  tumour,  over  600  were  enu- 
merated, and  many  flattened  clusters  and  very  small  isolated  ones  could 
not  be  counted.  At  this  time  anasarca  had  supervened.  She  died  para- 
plegic two  months  later,  having  for  some  time  previously  experienced  intense 
aching  pains  all  over.  There  was  no  necropsy.  Histological  examination 
of  the  excised  tumours  revealed  solid  branching  columns  of  epithelial-like 
cells  embedded  in  fibrous  stroma  ;  the  cells  were  of  flattened,  ovoid,  rounded 
or  irregular  shape,  large,  nucleated,  and  presented  no  signs  of  epidermic 
evolution. 


S    V, Myxoma. 

This  is  a  rare  form  of  mammary  neoplasm,  since  of  my 
2,397  female  cases  there  were  only  two  examples  of  it. 

In  their  main  features  myxomata  of  the  breast  closely 
resemble  sarcomata,  of  which  they  are  evidently  but  a  sub- 
variety.  The  chief  pathological  consequences  of  the  histological 
diversity,  subsisting  between  these  two  forms  of  the  disease  are, 
that  the  myxomata  rarely  originate  metastases  ;  and  that  they 
recur  locally  after  removal  much  less  frequently  than  other  sar- 
comata. Like  the  latter,  most  myxomata  originate  in  the 
immediate  vicinity  of  the  small  ducts,  hence  they  usually  con- 
tain glandular  structures,  whence  cysts  with  intra-cystic  growths 
frequently  evolve,  as  in  the  adeno-cystic  sarcomata.  Myxomata 
arc  also  met  with  devoid  of  any  glandular  structures  ;  these 
originate  from  the  fibro-fatty  tissue  of  the  organ   remote  from 


MYXOMA.  45 1 

the  ducts,  and  their  structure  often  comprises  a  considerable 
amount  of  fatty  tissue.'*'* 

Mammary  myxomata  generally  present  as  ovoid,  circum- 
scribed, lobulated  tumours,  of  elastic  consistence,  and  about  the 
size  of  hen's  eggs.  They  are  enclosed  in  a  thin  fibrous  capsule, 
which  isolates  them  from  the  surrounding  parts.  In  most  cases 
they  are  mobile,  but  not  infrequently  they  adhere  to  the  over- 
lying skin,  which  may  ulcerate,  and  so  the  growth  may  fungate. 
They  jdo  not  cause  retraction  of  the  nipple,  and  dissemination 
in  the  axillary  glands  is  very  exceptional. 

On  section  the  myxomatous  tissue  seldom  presents  the  clear, 
glassy  appearance  of  pure  mucous  tissue,  such  as  is  typically 
seen  in  the  jelly-fish  ;  instead  there  is  revealed  a  translucent, 
yellowish,  or  greyish  gelatinous  substance — -which  exudes  a 
viscid  fluid — with  various  opaque  or  semi-opaque  areas  irregu- 
larly scattered  throughout  it,  due  to  fatty  changes,  &c.  Histo- 
logically this  tissue  consists  of  stellate  and  spindle  cells,  which 
communicate  by  means  of  numerous  fine  processes,  and  the 
meshes  of  the  network  thus  formed  are  filled  with  mucous 
substance.  Numerous  capillary  blood  vessels  pervade  the  tissue, 
and  not  infrequently  round  and  ovoid  cells  are  also  present. 
Billroth  found  a  number  of  lentil-like,  osseous  nodules  in  a 
mammary  myxo-sarcoma.  In  some  varieties  the  mucous 
element  predominates,  in  others  the  cellular,  and  in  yet  others 
the  fibrous,  fatty,  or  vascular  elements.  When  the  neoplastic 
cells  themselves  degenerate  pseudo-cysts  often  result.  The 
complications  arising  from  the  cystic  evolution  of  the  included 
glandular  structures  are  identical  with  those  met  with  in  the 
adeno-cystic  sarcomata,  and  need  not  be  further  alluded  to. 

Mammary  myxomata  require  to  be  treated  in  accordance 
with  the  same  principles  as  mammary  sarcomata.  The  prog- 
nosis  is,    however,    more   favourable   than    for   the  latter  ;   for. 


**  In  the  midst  of  a  myxomatous  tumour  of  six  years'  growth,  removed  from  the 
breast  of  a  multipara,  aged  35,  Moore  found  a  distinct  lipoma.  Dul>.  Jonrn.  Med. 
Sci.,  vol.  Ixiii.,  p.  489. 


452  SARCOMA    OF    THE    BREAST. 

according  to  Gross,^^  local  recurrences  after  removal  are  met 
with  only  in  i6"6  per  cent,  of  all  cases. 

The  period  of  life  at  which  the  disease  supervenes  is  much 
the  same  as  that  for  sarcoma.  Ashby  and  Wright  have  figured 
an  instance  of  congenital  myxo-lipoma  of  the  breast  in  their 
treatise  on  the  diseases  of  children,  but  they  give  no  history  of 
the  case. 

As  an  example  of  the  malignant  form  of  the  disease  the 
following  case  by  Morris^^  is  of  interest : — 

A  widow,  aged  38,  in  delicate  health,  with  a  tumour  four  inches  in 
diameter  in  her  left  breast.  About  six  months  previously  she  first  noticed 
two  lumps  in  the  breast  ;  these  subsequently  fused,  and  from  them  the 
tumour  grew.  There  was  no  enlargement  of  the  axillary  glands.  The 
breast  was  amputated,  and  the  patient  was  convalescent  in  about  six  weeks. 
A  month  later  she  again  came  under  treatment  with  local  recurrence,  which 
was  excised  ;  but  shortly  afterwards  the  disease  recurred  again  and  was 
again  excised.  On  section  after  removal  the  primary  tumour  presented 
to  the  naked  eye  several  spaces  filled  with  gelatinous  fluid  ;  the  rest  of  it 
consisted  of  soft  solid  substance  of  greyish  colour,  mottled  with  plum- 
coloured  streaks.  It  was  enclosed  in  a  thin  capsule.  Histological  examina- 
tion revealed  fibrous  tissue,  spindle  cells,  and  irregularly  shaped  branching 
cells,  communicating  with  one  another,  and  forming  a  network,  in  the 
meshes  of  which  mucoid  fluid  was  contained.  A  year  after  the  last  opera- 
tion, the  patient  again  came  under  treatment,  complaining  of  great  pain  in 
the  right  side  of  her  chest  and  hacking  cough  ;  there  was  dulness  as  high  as 
the  fourth  rib.  She  died  of  exhaustion  a  month  later.  At  the  necropsy  the 
mammary  region  and  axilla  were  found  to  be  quite  free  from  the  disease. 
From  the  posterior  part  of  the  right  lobe  of  the  liver  there  projected  upwards 
a  mass  of  new  growth,  the  size  of  the  foetal  head,  which  had  compressed  the 
right  lung  and  displaced  it  upwards.  There  were  some  secondary  growths 
in  the  left  lung.  Histologically,  the  secondary  growths  were  of  similar 
structure  to  the  primary  one  in  the  mamma,  only  they  contained  rather 
more  spmdle  cells. 

§    VI. Keloid  and  its  Allies. 

One  of  the  favourite  scats  of  origin  of  keloid  is  the  skin  over 
the  sternum,  but  occasionally  it  originates  from  the  mammary 
integument.     The  disease  is  decidedly  rare.     As  to  the  precise 

"  "Am.  Syst.  Gyn.,"  vol.  ii.,  p.  259. 

*"   'ira7is.  Path.  Soc.  Loud.,  vol.  xxiii.,  p.  274,  &c. 


KELOID    AND    ITS    ALLIES.  453 

morbid  conditions  to  which  the  term  keloid  is  applicable 
although  there  is  much  diversity  of  opinion,  two  distinct  types 
may  be  recognised. 

(i)  In  the  commoner  form,  the  disease  usually  presents  as  an 
oblong,  flattened  outgrowth  from  the  derma,  of  smooth,  purplish- 
red  aspect,  much  resembling  an  overgrown  and  irritated  scar. 
Indeed,  it  is  from  cicatricial  tissue  that  such  growths  usually 
arise.  Hence  Virchow  has  described  them  as  sarcomata  of 
scars.  Occasionally,  however,  they  evolve  spontaneously.  This 
is  the  type  of  the  disease  denominated  by  Alibert  kelis  {icr]\i^ 
=  blemish).  Growths  of  this  kind  resemble  sarcomata,  in  that 
they  recur  locally  again  and  again,  even  after  very  free  removal. 
A  notable  peculiarity  about  these  recurrences  is,  that  they  some- 
times occur  not  only  in  the  extirpation  scars,  but  also  in  any 
little  scars  that  happen  to  have  been  made  in  the  vicinity  by  the 
use  of  sutures,  needles,  leeches,  &c.  In  such  cases  it  is  impos- 
sible to  avoid  the  inference  that  the  morbid  tendency  thus  mani- 
fested appertains  to  the  locality,  as  well  as  to  the  structure. 
They  also  resemble  sarcomata  in  that  they  do  not  disseminate 
in  the  adjacent  lymph  glands  ;  but,  unlike  most  sarcomata,  these 
growths  are  not  encapsuled,  and  they  never  cause  metastases. 
Histologically  they  consist  of  immature  fibrous  tissue,  containing 
numerous  nuclei,  with  generally  some  round  and  spindle  cells 
intermixed.  When  the  question  of  treatment  is  under  con- 
sideration, it  is  well  to  remember  that,  having  attained  a  certain 
size,  the  disease  often  ceases  to  increase.  Moreover,  under  the 
influence  of  soothing  applications,  it  sometimes  manifests  a  ten- 
dency to  spontaneous  resolution.  Consequently,  operative  in- 
terference, caustic  and  irritant  applications  should  be  sedulously 
avoided.  The  best  treatment  is  to  cover  up  the  lesion  with 
belladonna,  salicylic  acid,  or  ammoniacum  cum  hydrargyro 
plaster. 

The  following  example  of  this  disease  in  the  breast  has  come 
under  my  notice  : — 

*  Path,  des  Tttijieurs,  I.  ii.,  p.  239. 


454  SARCOMA    OF    THE    BREAST. 

A  well-nourished,  fair  complexioned,  healthy  looking  woman,  aged  51, 
the  mother  of  five  children,  with  a  hard  red  nodule,  the  size  of  a  pea,  pro- 
jecting slightly  from  the  skin  at  the  upper  part  of  the  periphery  of  the  left 
bosom.  Fourteen  years  ago  she  had  a  boil  in  this  situation,  which,  when  it 
healed,  left  a  small  scar  ;  the  present  disease  has  sprung  from  this  scar 
during  the  last  six  months.  No  enlargement  of  the  adjacent  lymph  glands. 
Previous  health  good.  No  family  history  of  cancer  or  tumour.  The  growth 
was  excised,  together  with  a  rim  of  the  surrounding  integument.  On 
examination,  after  removal,  it  presented  as  a  thickening  of  the  derma.  Its 
section  presented  a  dense,  whitish-yellow  fibroid  aspect.  On  microscopical 
examination  a  fibrous  felt-work  was  seen  rich  in  nuclei,  with  a  few  small 
round  and  spindle  cells  embedded  in  it.  She  was  soon  convalescent,  and  I 
have  since  seen  nothing  more  of  her. 

Velpeau*^  has  recorded  the  subjoined  instructive  case  : — 

A  young  lady  of  great  beauty  consulted  him  for  a  small  reddish  growth, 
projecting  from  the  integument  of  the  inner  side  of  the  left  bosom.  It 
caused  her  no  pain,  but  its  presence  was  a  source  of  great  annoyance.  She 
got  a  surgeon  to  excise  it,  but  six  months  later  a  fresh  tumour  had  formed  in 
the  scar  bigger  than  the  first.  A  second  operation  soon  afterwards  was 
followed  by  a  similar  result.  When  Velpeau  first  saw  her,  some  months 
after  the  second  operation,  there  was  a  projecting  smooth,  reddish  plaque  in 
the  scar  (3  cm.  x  2^  cm.).  The  deformity  worried  her  very  much,  and  she 
shrank  from  no  risk  to  be  rid  of  it.  Velpeau  therefore  excised  it  for  the 
third  time  ;  but  although  the  wound  united  by  first  intention,  recurrence 
soon  afterwards  took  place.  Then  the  lady  in  despair  gave  up  all  attempts 
at  cure,  and  subsequently  the  tumour  diminished  spontaneously. 

In  a  case  reported  by  Bryant,^**  eight  years  after  excision  of  a  fibro- 
adenoma of  six  months'  duration,  from  the  left  breast  of  an  unmarried  lady, 
aged  34,  a  typical  keloid  growth  developed  in  the  old  scar.  This  was 
subsequently  excised,  and  there  was  return  of  the  disease  five  years  after- 
wards. 

The  following  case  of  lupus-keloid  is  by  Hutchinson  :^^ — 

A  widow  lady,  aged  50,  came  under  observation  with  a  purplish-red, 
slightly  raised,  indurated,  horse-shoe-shaped  patch  —rather  larger  than  a 
crown  piece — on  the  inner  side  of  her  right  bosom.  Unlike  ordinary  keloid, 
it  had  a  shelving  edge  that  merged  gradually  into  the  surrounding  integu- 
ment ;  moreover,  instead  of  its  surface  being  smooth  and  glossy,  as  in 
ordinary  keloid,  it  was  rough,  showing  the  orifices  of  hair  follicles.  The 
disease  began  about  twenty  years  ago,  and  it  has  ever  since  been  spreading 
very  slowly,  but  there  has  never  been  the  least  ulceration.  It  had  been 
diagnosed  some  years  previously  by  a  skin  specialist  as  lupus  erythematosus. 


"  "  Traite  des  Maladies  du  Sein,"&c.,  1854,  p.  467. 

*■*  "Diseases  of  the  Breast,''  p.  iii. 

'■■'  Archives  of  Surgery^  Oct.,  1891,  p.  129. 


KliLOIl)    AND    ITS    ALLIES.  455 

She  had  a  scar  on  the  left  side  of  her  nose,  which  resulted  from  the  cure  of 
a  patch  of  lupus  erythematosus^  after  repeated  applications  of  the  galvanic 
cautery,  &c.,  five  years  ago.  With  regard  to  the  treatment  of  the  patch  on 
the  breast,  she  was  advised  to  leave  it  alone. 

(2)  The  rarer  form  of  the  disease  is  characterised  by  the 
formation  in  the  derma  of  whitish,  ivory-Hke,  sHghtly  elevated, 
indurated  areas,  which  feel  firm  and  elastic,  each  being  sur- 
rounded by  a  faint,  lilac-coloured  vascular  areola.  It  seems  in 
reality  to  be  a  localised  sclero-derma.  From  it  numerous  fibroid 
processes  often  extend  far  into  the  surrounding  structures  ;  and, 
in  connection  with  these,  satellite  nodules  may  develop,  This  is 
the  form  termed  by  Addison  cJieloid  {xqtJr]  =  crab's  claw).  The 
disease  begins  with  proliferative  changes  in  the  fibro-cellular 
tissue  surrounding  the  adventitia  of  the  small  arteries  of  the 
derma,  and  by  its  spread  along  similar  channels,  the  outlying 
processes  arise.  The  result  is  considerable  overgrowth  of  the 
fibrous  tissues  in  the  parts  affected.  If  left  alone  it  generally 
progresses,  but  very  slowly ;  and  after  a  time  retrogressive 
changes  sometimes  supervene  spontaneously. 

The  following   interesting  cases — in  which  the  breast   was 

involved — are  by  Hutchinson  -P — 

{a)  A  comely  married  woman,  aged  40,  with  extensive,  irregular  thickening, 
sclerosis,  and  fixation  of  the  skin  over  the  left  pectoral  region,  shoulder, 
deltoid  region,  front  of  the  arm,  and  the  radial  border  of  the  forearm,  thumb, 
and  finger.  In  some  of  the  affected  parts  there  are  groups  of  ivory-like, 
lardaceous,  shining  patches,  which  send  out  spurs  ;  but  the  appearance  of 
most  of  the  thickened  integument  resembles  that  of  kelis,  and  in  some  places 
it  looks  very  like  cancerous  infiltration  en  cuirasse.  In  consequence  of  this 
fixed  and  tightened  condition  of  the  skin,  the  movements  of  the  limb  are 
much  impaired.  Numerous  small  subcutaneous  tubercles,  not  larger  than 
hazel  nuts,  are  present  in  the  diseased  parts.  Some  similar  reddish  indurated 
patches,  occur  in  the  skin  of  the  front  and  outer  parts  of  the  left  leg  and  the 
second  toe.  This  curious  disease  began  with  the  development  of  a  single 
morphoea-like  node  in  the  skin,  above  the  left  breast,  six  or  seven  years 
previously.  It  remained  without  obvious  change  until  about  a  year  ago, 
when  there  was  sudden  outbreak  of  the  disease  on  all  the  four  extremities, 
but  chiefly  on  the  left  side.  The  lesions  of  the  right  side  subsequently  almost 
entirely  disappeared.  Three  and  a-half  years  later  she  again  came  under 
observation.     Her  general  health  then  was  very  good.     The  skin  of  the  left 


'■'''Archives  of  Stirgoy,  July,  1891,  pp.  jo  and  34;   also  July,  1890,  p.  32. 


456  SARCOMA    OF    THE    BREAST. 

pectoral  legion,  from  the  clavicle  to  the  nipple,  was  occupied  by  a  dusky- 
brown  thickened  induration,  by  which  it  was  bound  firmly  to  the  subjacent 
parts.  Nothing  but  knowledge  of  the  previous  history  of  the  case,  and 
e.xamination  of  the  similar  lesions  in  other  parts  of  the  body,  could  have 
prevented  the  diagnosis  of  cancer  en  cuirasse.  In  the  deltoid  region  there 
were  a  few  ivory-like //a^z/^j  and  atrophic  patches,  where  the  disease  seemed 
to  have  receded.  There  were  also  atrophic  areas  along  the  course  of  the 
upper  limb  where  the  nodules  had  been  most  marked,  and  both  hands  were 
considerably  affected  with  diffuse  scleroderma. 

(jb)  A  single  lady,  aged  23,  with  lardaceous  thickening  and  tightening  of 
the  skin  of  both  mammary  regions,  the  face,  and  both  upper  and  lower  ex- 
tremities, due  to  diffuse  scleroderma.  She  said  the  disease  came  on 
gradually  three  years  previously,  owing  to  grief  at  the  death  of  her  mother. 
Symptoms  of  Raynaud's  disease  subsequently  developed,  and  when  next 
seen  three  years  later,  both  forefingers  were  necrotic. 

{c)  A  widow  lady,  aged  45,  apparently  in  excellent  health,  applied  under 
the  belief  that  she  was  suffering  from  cutaneous  cancer  of  the  breast.  About 
eight  months  previously  she  first  noticed  a  patch  of  indurated  skin  just  in 
front  of  the  left  axilla.  At  a  consultation  a  fortnight  later  two  patches  were 
noticed  there,  each  about  the  size  of  a  florin.  They  seemed  to  consist  of 
firm,  leathery,  cutaneous  induration,  and  they  were  of  mottled  pinkish-yellow 
tint.  Two  subcutaneous  nodules  could  be  felt  in  their  vicinity.  No  known 
cicatrix  had  previously  existed,  so  far  as  the  patient  knew,  in  the  site  of 
either  patch.  The  axilla  fell  normal.  It  was  evidently  an  instance  of  ivory- 
like morphoea  patches,  and  not  cancer. 

§     VI  1.^ Sarcoma  of  the  Male  Breast. 

From  such  instances  of  sarcomatous  disease  of  the  male 
breast  as  have  hitherto  been  recorded,  it  may  be  inferred  that  all 
the  above  described  varieties  met  with  in  the  female  breast  may 
also  be  found  in  it,  although,  of  course,  such  occurrences  are  of 
great  rarity.*  Most  of  the  recorded  cases  known  to  me  have 
been  pure  sarcomata,  as  in  ^le  four  following  examples  : — 

(i)  ■''  A  man,  aged  43,  a  week  previously  first  noticed  a  small,  hard  lump 
in  his  left  breast,  just  above  and  internal  to  the  nipple.  No  previous  injury 
or  other  known  cause.  His  father  died  of  "  cerebral  tumour."  It  increased 
rapidly.  On  examination,  a  hard,  elastic,  elongated  nodular  tumour  was 
found  there,  which  was  freely  movable  under  the  skin  and  over  the  pectoral 
muscle.  There  was  no  retraction  of  the  nipple,  and  the  axillary  glands  were 
normal.  A  fortnight  later  the  breast  was  amputated.  The  tumour  was 
enclosed  in  a  thick  capsule,  and  on  section  it  was  composed  of  solid  sub- 


For  table  showing  its  relative  frequency  vide  p.  130. 

Haslam,  Birinini^ham  Medical  Review,  vul.  xxv.,  1889,  p.  286. 


SARCOMA    OK    THE    MALE    BREAST.  45/ 

stance,  containing  a  few  small  cysts.  Histologically,  the  solid  substance 
consisted  almost  entirely  of  small  round  cells,  with  the  characteristic  grouping 
o{  lyniplio-sarcoma.     He  was  convalescent  about  three  weeks  later. 

(2)  -''^  A  labourer,  aged  y]^  strong  and  healthy-looking,  came  under  obser- 
vation with  a  large  fungating  and  eroded  tumour  of  the  right  breast  of  seven 
years'  duration.  It  was  hard,  lobulated,  circumscribed,  and  freely  movable 
on  the  subjacent  parts.  Its  circumference  measured  27  inches.  There  was 
profuse  foetid  discharge  from  it.  No  enlargement  of  the  adjacent  lymph- 
glands.  The  patient  ascribed  the  origm  of  the  disease  to  the  effect  of  a 
blow  from  a  heavy  piece  of  iron.  His  mother's  sister  died  of  a  malignant 
tumour  of  the  breast,  which  recurred  twice  after  removal.  The  diseased 
part  was  amputated.  The  tumour  weighed  2lbs.  after  removal.  It  was  a 
spindle-cslled  sarcoma.     He  was  convalescent  soon  after. 

(3)  ^^  A  soldier,  40  years  old,  with  a  nodular  tumour,  the  size  of  a  walnut, 
projecting  from  the  right  mammary  region.  The  overlying  skin  was 
purplish,  and  marked  with  dilated  veins.  It  was  situated  above  and  external 
to  the  nipple.  It  felt  firm  and  elastic.  About  22  years  ago  the  patient  first 
noticed  a  small  nodule  in  the  site  of  the  present  tumour.  Its  increase  was 
hardly  perceptible  until  about  five  years  ago.  Amputation  of  the  diseased 
part.  On  examination  after  removal,  the  tumour  was  found  to  consist  of 
three  nodules,  united  by  dense  fibroid  tissue.  The  smaller  one  was 
obviously  connected  with  the  mammary  gland,  but  not  so  the  other  two. 
On  section  the  tumour  presented  a  convex,  nacreous,  fibroid  aspect.  His- 
tologically, fibro-spindle-celled  sarcoma. 

(4)  '"^  A  man,  aged  21,  eight  months  previously  first  noticed  a  mobile 
lump,  the  size  of  a  horse  bean,  external  to  the  left  nipple  over  the  edge  of 
the  pectoralis  major  muscle.  This  subsequently  increased  in  size  and  the 
axillary  glands  became  enlarged.  The  diseased  part  was  excised  and  the 
axilla  cleared.  Five  months  later  he  again  came  under  observation  with 
recurrence  high  up  in  the  axilla  and  in  the  glands  at  the  root  of  the  neck, 
and  in  the  mammary  region.  The  disease  spread  with  terrible  rapidity.  In 
attempting  to  clear  the  axilla  a  mass  of  soft  new  growth  was  found  to  have 
completely  surrounded  the  large  blood  vessels,  &c.,  and  it  could  only  be 
partly  removed.  He  died  six  weeks  later,  and  at  the  necropsy  secondary 
growths  were  found  in  both  lungs.  Histologically  the  disease  was  round- 
celled  sarcoma. 

Instances  of  adeno-cystic  sarcoma  have  been  recorded  by 
Birkett,^^  Amado,^*^  and  others ;  while  Rothmann^''  has  met  with 
an  example  of  alveolar  sarcoma^  and  Obolensky*'^  with  an  adeno- 
inyxoma. 

^'^  Morton,  Glasgow  Medical  Journal,  vol.  xiv.,  1880,  p.  157. 

5'  Ward,  Trans.  Path.  Soc.  London,  vol.  xi.,  i860,  p.  268. 

"  Banks,  "  Clinical  Notes,"  1884,  p.  69. 

55  "  Diseases  of  the  Breast,"  1850,  p.  257. 

5^  Correio  Med.  de  Lisboa,  1871-2,  vol.  i. ,  p.  210. 

"  "  Ein  P'all  vuo  cysliche  Endothelium  der  miinnlich  Brusl."'     Wurzb.,  1S91. 

'"^  Cited  in  Labbe  and  Coyne's  Traile  des  Tttineurs  Benignes  dii  Seiii,  p.  553. 


458 


CHAPTER  XVIII. 

Fibroma  and  Fibro-Adenoma. 


S     I . Pure  Fibroma. 

According  to  Billroth^  and  Schimmelbusch;^  mammary 
fibromata  always  contain  glandular  structures.  This  is  too 
sweeping  a  statement,  for  pure  fibromata  of  the  breast  are  un- 
doubtedly occasionally  met  with.  Among  the  2,397  cases  of 
mammary  neoplasms  in  women  analysed  by  me,  there  was  one 
instance  of  this  kind.  It  is  difficult  to  account  for  their  great 
rarity,  considering  the  abundance  of  the  fibrous  tissue  of  the 
part.  In  their  general  characters  such  growths  precisely 
resemble  the  ordinary  fibrous  tumours  of  the  subcutaneous 
tissue,  &c. 

Lancereaux^  figures  a  good  specimen  from  Pean's  collection,  showing  two 
rather  large  tumours  of  this  kind,  situated  over  the  front  of  the  gland,  imme- 
diately beneath  the  skin. 

In  the  Hunterian  Museum  there  are  three  somewhat  similar 
specimens,  which  in  the  catalogue*  are  described  as  follows  : — 

(i)  No.  4,775A.  A  tumour,  o»e  inch  in  diameter,  of  fibrous  appearance, 
from  the  surface  of  the  mammary  gland.  Histological  examination  showed 
only  fibrous  tissue,  without  any  trace  of  glandular  elements.  From  a  woman 
aged  44. 

(2)  No.  4,776.  An  encapsuled  fibroma,  of  eighteen  months'  duration, 
from  the  right  breast  of  a  married  multipara,  aged  53.  Histologically  it  was 
composed  of  fibrous  tissue,  containing  but  few  nuclei. 

'  Deutsche  Ckir.,  Lief,  xli.,  S.  43. 
-  Arch.  f.  klin.  Chir.,  Bd.  xliv.,  1892,  S.  102. 
^  "Traile  d'Anat.  Path.,"  t.  i.,  1875,  p.  377. 
'  •'  Path.  Catalogue,"  vol.  iv.,  1885,  p.  477. 


PURE    FIBROMA.  459 

In  another  bpecimen  of  this  kind  the  tumour  weighed  seven  pounds, 
and  was  of  thirteen  years'  growth.  The  patient  was  a  middle-aged  woman. 
The  tumour  was  situated  behind  the  gland. 

Broca"'  mentions  having  met  with  two  instances  of  fibroma  in  the  mam- 
mary region.  In  one  the  tumour  was  situated  beneath  the  gland,  between 
it  and  the  pectoralis  major  muscle  ;  in  the  other  it  was  situated  under  this 
muscle.  In  neither  case  had  the  tumour  any  connection  with  the  gland 
itself. 

Some  of  the  polypoid  growths  met  with  within  the  large  ducts,  are 
occasionally  purely  fibromatous  in  structure  (!;''fibro)ne  iiitra-canaliculair^^ ). 

Paget^  has  recorded  the  following  remarkable  case  of  malig- 
nmit  fibroma,  which  is  of  great  interest,  from  whatever  point  of 
view  we  regard  it. 

A  poor  widow,  aged  47,  crippled  from  chronic  rheumatism,  came  under 
observation  with  a  mobile  tumour  in  her  right  breast,  which  had  increased 
but  very  slowly  until  seven  weeks  previously  ;  when,  after  an  injury,  it 
augmented  rapidly  and  became  very  painful.  A  spherical  tumour,  two  to 
three  inches  in  diameter,  soon  formed,  which  was  so  exceedingly  hard  as  to 
resemble  cancer.  The  whole  breast  was  extirpated.  On  examination  after 
removal,  the  tumour  was  circumscribed,  encapsuled  and  solid.  Its  cut  sur- 
face precisely  resembled  that  of  an  ordinary  fibroma.  The  most  careful 
histological  examination,  often  repeated,  revealed  nothing  but  well-formed 
fibrous  tissue,  with  embedded  elongated  nuclei  ;  on  boiling  it  yielded 
gelatine.  Three  months  after  this  operation  further  growth  appeared  under 
the  scar,  which  grew  very  quickly,  forming  a  tumour  very  like  the  primary  one. 
Two  months  later  the  overlying  tissues  began  to  ulcerate,  and  soon  after- 
wards the  whole  growth  separated  by  sloughing.  This  tumour  also  pre- 
sented the  characters — histological  and  otherwise — of  simple  fibroma.  The 
walls  of  the  large  sloughing  cavity,  left  after  the  separation  of  the  tumour 
soon  presented  hard  knots  of  recurrent  disease,  and  finally  they  were 
invaded  throughout  by  firm,  nodular,  whitish,  new  growth.  After  death 
numerous  secondary  growths  of  similar  appearance  were  found  in  both 
lungs,  which,  histologically  and  otherwise,  seemed  identical  with  unmixed 
fibrous  tissue. 

One  is,  of  course,  naturally  inclined  to  regard  such  o-rowths 
as  of  fibro-sarcomatous  nature  ;  but  it  is  strange,  after  repeated 
examinations  directed  specially  to  this  end,  that  no  sarcomatous 
elements  could  be  detected.  Having  myself  met  with  several 
similar  instances,  in  which  the  prognosis — based  upon  micro- 


•'  "  Traite  des  Tumeurs,"  t.  ii.,  p.  454. 

^  "  Lectures  on  Surgical  Pathology,"  vol.  ii.,  1855,  p.  151. 


460  FIBROMA    AND    FIBRO-ADENOMA. 

scopical  examination,  &c. — was    equally  at  fault,  I  have  been 

much  impressed  by  the  circumstance/ 

Small,  pedunculated,  fibrous  outgrowths  {i)iolltiscii7n  fibrosuni) 

from  the  skin  of  the  areola  and  nipple,  are  occasionally  seen. 

In  a  health)',  young-  adult  woman,  I  met  with  a  growth  of  this  kind,  close 
to  the  nipple,  that  looked  at  first  sight  very  like  a  redundant  nipple. 
Bryant^  mentions  a  somewhat  similar  case,  and  he  also  refers  to  an 
instance  in  which  a  fibrous  growth  sprang  from  the  apex  of  the  nipple. 
MacSwiney'-'  has  reported  an  example  of  pendulous  fibroma  of  this  part,  in 
which  the  tumour  attained  a  large  size,  its  pedicle  being  about  seven  inches 
long,  and  at  its  largest  circumference  the  tumour  measured  six  inches. 

S    II. — Fibro-Adenoma. 

At  the  beginning"  of  the  present  century  it  was  customary 
to  regard  all  mammary  tumours  as  of  a  malignant  nature.  To 
Astley  Cooper — the  beau  ideal  of  an  English  surgeon — belongs 
the  credit  of  having  been  the  first  to  discriminate  the  non- 
malignant  forms.  These  he  called  "  chronic  mammary  tumours." 
His  knowledge  of  the  subject  was  so  advanced,  that  had  the 
microscope  then  been  available,  it  is  evident  he  would  have 
left  very  little  for  his  successors  to  discover.  His  description 
of  these  tumours  is  as  follows  •}'^ — 

"  This  disease  is  not  of  a  malignant  character,  and  by  no  means  danger- 
ous to  life  ;  it  is  generally  very  young  people  who  are  attacked  by  it,  and 
we  seldom  see  it  in  persons  above  30  years  of  age.  I  will  try^  to  describe, 
in  a  familiar  manner,  the  mode  in  which  this  disease  will  be  exhibited  to 
you.  A  young  person  between  the  age  of  15  and  30,  will  be  brought  to 
you  by  her  parents,  on  account  of  a  swelling  in  her  breast  ;  when  you 
look  at  her,  you  see  that  she  has  a  perfectly  healthy  appearance,  and,  in 
all  probability,  is  much  younger  than  those  who  are  usually  attacked  by 
scirrhous  tubercle.  Her  parents  being  naturally  anxious  for  their  child's 
safety,  express  their  fears  of  the  disease  being  cancerous  ;  at  this  you  smile, 
and  tell  them  that  cancer  does  not  attack  persons  so  young  ;  upon  examin- 
ing the  breast  you  find  an  exceedingly  movable  tumour — the  size  of  which 
is  generally  from  that  of  a  filbert  or  walnut  to  that  of  a  billiard  ball  — 
having   a  lobulated  feel,  being  divided  into  distinct  apartments  by  septa, 

'  Medical  Press  and  Circular,  Nov.  28,  1888. 
*  "  Diseases  of  the  Breast,"  pp.  333  and  334. 
"  Dublin  Journal  oj  Medical  Science,  1875,  P-  4^4- 
"  •'  Lectures  on  Surgery,"  1S39,  p.  392. 


FIBRO-ADENOMA.  461 

producing  the  same  kind  of  sensation  to  the  fingers  as  fatty  tumours.  You 
have  here  (deHvering  a  preparation  to  a  student)  an  opportunity  of  seeing 
this  kind  of  tumour,  and  upon  carefully  examining  it,  you  will  find  that  the 
account  which  I  have  given  you  of  it  is  correct.  Well,  then,  the  age  and 
healthy  appearance  of  the  person,  and  the  lobulated  feel  of  the  tumour,  will 
at  once  point  out  to  you  that  the  disease  is  not  cancerous  ;  which,  gentle- 
men, you  may  inform  the  person's  parents,  and  likewise  tell  them  that  the 
disease  will  never  become  cancerous.  I  can  assure  you  that  this  disease  is 
not  in  the  slightest  degree  of  a  malignant  character,  neither  is  it  attended 
with  the  least  danger." 

Cooper's  views  were  soon  accepted  in  England  ;  but  else- 
where they  penetrated  very  slowly.  Thus  in  France,  shortly 
afterwards  (1839),  we  find  Velpeau  describing  these  same 
tumours  as  '' tiuneiirs  fibriueuses"  for  he  thought  they  were 
nothing  but  deposits  of  inspissated  fibrine,  left  behind  after 
localised  extravasations  of  blood.  Some  years  later  (1844;,  the 
celebrated  Cruveilhier  communicated  to  the  Royal  Academy  of 
Medicine  his  much-discussed  Memoire,  in  which  he  maintained 
that  these  tumours  were  veritable  fibromata,  "  corps  fibreux," 
as  he  called  them.  The  next  step  forward  was  by  Lebert,  who 
some  years  later,  with  the  aid  of  the  microscope,  first  clearly 
demonstrated  the  presence  of  glandular  structures ;  whence 
he  described  them  as  "hypertrophies  partielles"  of  the  gland. 
Soon  afterwards  Velpeau,  having  convinced  himself  of  the 
accuracy  of  Lebert's  observations,  rechristened  them  "  tunieiirs 
adenoides."  The  identity  of  these  variously  named  tumours 
with  one  another,  and  with  the  "  chronic  mammary  tumours  " 
of  Cooper,  then,  at  length,  became  generally  recognised. 

These  investigations  having  demonstrated  that  the  tumours 
consist  of  both  fibroits  and  glandidar  structures,  the  question 
then  arose,  as  to  which  was  the  essential  constituent.  It 
cannot  be  said  that  this  has  even  yet  been  definitely  settled  ; 
in  fact,  being  at  bottom  essentially  a  genetic  question,  its 
solution  must  perhaps  ever  be  mainly  a  matter  of  inference. 
Accordingly  we  need  not  be  surprised  to  meet  with  divergent 
interpretations.  Thus,  while  Virchow  and  most  German  patho- 
logists, together  with  Labbe  and  Coyne,  Cornil  and  Ranvier, 
and  Gross,  regard  these  growths  as  fibromata  ;  Broca,  Verneuil, 
Cadiat,    Delbet   and    others,    consider   them    as    essentially    of 


462  FIBROMA    AND    FIBRO-ADFNOMA. 

glandular  origin,  or  adenomata.  Since  physiological  impulses 
in  the  breast  manifest  themselves  mainly  through  its  glandular 
elements;  it  seems  only  reasonable  to  suppose  that  the  stress 
of  its  pathological  impulses  will  fall,  also,  chiefly  on  these. 
Believing,  as  I  do,  that  the  immense  majority  of  these  growths 
arise  from  portions  of  the  breast,  where  both  the  glandular 
and  fibrous  elements  are  intimately  blended,  that  is  to  say,  from 
the  small  ducts  and  their  immediate  vicinity  ;  it  seems  to  me 
highly  probable  that  both  factors  participate  in  the  origin  of 
the  disease  ;  which  may,  therefore,  with  propriety  be  designated 
fibro-adenoma. 

Unfortunately,  instead  of  restricting  the  term  "  adenoma  " 
exclusively  to  such  growths  as  the  foregoing,  many  pathologists 
have  given  it  a  much  wider  application.  Hence,  so  many 
different  kinds  of  neoplasm  have  come  to  be  included  under 
this  heading,  that  hardly  any  two  pathologists  now  employ  the 
term  in  the  same  sense.  By  Gross  it  is  applied  to  "  tubular 
cancers  "  and  "  villous  duct  papillomata  "  ;  the  latter  are  also 
thus  designated  by  Billroth,  who,  under  this  heading,  includes 
as  well  "  the  partial  glandular  hypertrophies,"  and  it  is  in  the 
latter  sense  that  the  term  is  used  by  Cornil  and  Ranvier. 

"  True  adenoma  "  is  the  name  given  by  some  pathologists  to 
tumours  structurally  exactly  like  a  segment  of  the  breast  itself, 
only  not  united  to  the  gland  by  its  main  duct.  Tumours  of 
this  kind  undoubtedly  occur  ;  and  it  is  such  as  these  that  have 
occasionally  been  observed  to  secrete  milk.  A  thorough  ex- 
amination of  this  subject,  in  connection  with  my  investigations 
relating  to  supernumerary  mammary  sequestrations,  has  con- 
vinced me  ;  that  in  these  cases  we  have  to  do  with  overgrown 
supernum.crary  mammary  sequestrations,  rather  than  with  true 
neoplasms.  Such  I  believe  to  be  the  nature  of  Birkett's  two 
remarkable  cases,^^  of  which  an  epitome  is  subjoined  : 

(i)  Soon  after  marriage,  a  healthy  young  woman,  aged  21,  first  noticed  a 
small  lump  in  the  axillary  region  of  her  left  breast.     Her  first  child  was  born 


"  Guy's  Hosp.  Rep.,  1855. 


FIBRO-ADENOMA.  463 

within  a  year,  and  she  suckled  it  for  nearly  ten  months,  becoming  pregnant 
again  while  doing  so.  She  came  under  observation  when  about  six  months 
gone  in  this  second  pregnancy.  The  left  breast  then  was  about  double  the 
size  of  the  right,  owing  to  the  presence  of  ill-defined,  quasi-fluctuating 
swelling  in  its  axillary  segment.  The  nipple  was  displaced  inwards,  but 
it  was  not  retracted.  After  parturition  in  due  course,  a  definite  tumour 
was  for  the  first  time  distinctly  made  out.  Whilst  suckling  this  child  milk 
abscesses  formed  in  her  left  breast.  Some  months  later  she  became  preg- 
nant again,  and  in  due  course  a  third  child  was  born,  which  she  suckled  for 
a  month,  when  it  died.  At  this  time  a  circumscribed,  lobular,  mobile,  solid 
tumour,  quite  isolated  from  the  breast,  could  be  made  out.  About  a  year 
later  the  tumour  having  continued  to  increase,  was  excised.  In  the  course  of 
the  dissection,  it  was  found  to  be  encapsuled  and  isolated  from  the  mammary 
gland,  which  was  not  injured  by  its  removal.  The  tumour  weighed  three 
pounds.  Its  structure  closely  resembled  that  of  the  normal  mamma,  con- 
sisting of  loosely  connected  lobes,  each  composed  of  lobules,  and  these  again 
of  aggregates  of  acini.  The  smaller  ducts  from  these  sources  united  to  form 
larger  ones  ;  the  distal  ends  of  which  terminated  on  the  surface  of  the  mass. 
In  this  vicinity  there  was  a  large,  thin-walled  cyst,  as  if  due  to  a  dilated 
main  duct,  which  was  distended  with  soft,  solid  substance  resembling  thick 
cream,  and  on  chemical  examination  its  composition  was  found  to  be  very 
cream-like.  Not  far  distant  from  this  cyst  was  a  smaller  one,  filled  with 
cretaceous  material. 

(2)  A  healthy,  unmarried  woman,  aged  23,  three  and  a-half  years  ago 
first  noticed  a  lump  in  her  left  breast.  The  catamenia  did  not  appear  until 
19,  when  they  ceased  for  nearly  a  year,  and  at  about  the  time  they  re-ap- 
peared the  breast  tumour  began  to  enlarge.  On  examination  a  well  defined 
lobulated  tumour  could  be  felt,  which  seemed  to  be  situated  behind  the 
sterno-clavicular  segment  of  the  mamma.  It  was  excised  some  months  later, 
without  the  breast  sustaining  any!  injury.  On  examination  after  removal  it 
proved  to  be  an  exceedingly  firm,  dense,  lobulated  tumour — structurally, 
very  like  the  normal  mamma — consisting  of  numerous,  closely-packed,  small 
lobes  and  lobules,  many  of  whose  chief  ducts  were  distended  with  a  sub- 
stance exactly  resembling  cream.  It  seemed  probable  that  this  person  was 
a  virgin. 

The  following  case  of  so-called  true  adenoma,  by   D'Arcy 

Power,^^  is  evidently  of  sinnilar  nature. 

A  lady,  four  months  pregnant,  five  months  ago  first  noticed  a  tumour  in 
her  breast,  which  subsequently  was  excised.  It  was  encapsuled,  lobulated 
and  nodular  ;  four  and  a-half  inches  by  two  inches  in  diameter.  In  section  it 
was  of  pearly  white  appearance,  like  freshly  cut  mammary  gland.  Histologi- 
cally it  consisted  of  fibrous  stroma  in  which  were  embedded  lobular  and 
acinous  structures,  like  those  of  the  normal  mamma,  but  less  regularly 
arranged. 

'■-  Trans.  Path.  Soc.  Load.,  vol.  xxxvi.,  1S85,  p.  411. 


464  FIBROMA    AND    FIBRO-ADENOMA. 

I  have  previously  cited  many  other  examples  of  tumours 
and  tumour-like  swellings  thus  arising.^^ 

With  regard  to  the  general  morpJiology  of  this  disease  it  may 
be  mentioned  that  although  fibro-adenomata  are  usually  solitary, 
yet  more  than  a  single  tumour  is  occasionally  met  with.  Of 
forty-six  cases  consecutively  under  my  observation,  forty-four 
were  solitary ;  of  the  other  two  cases,  in  one  several  small 
tumours  were  present  in  both  breasts,  and  in  the  other  there 
were  two  small  tumours  in  the  affected  breast.  These  multiple 
tumours  usually  evolve  successively  at  different  periods.  I 
have  never  met  with  an  instance  in  which  the  disease  developed 
simultaneously  in  both  breasts.  In  this  connection  it  may  be 
mentioned,  that  after  the  removal  of  one  tumour  another  has 
been  known  to  form  in  the  same  vicinity,  or  in  a  different 
part  of  the  same  breast,  or  even  in  the  opposite  breast. 

According  to  my  experience  the  left  breast  is  more  fre- 
quently affected  than  the  right,  in  the  proportion  of  33  to  19. 
Of  Velpeau's  54  cases,  27  were  of  the  left  breast,  22  of  the  right, 
and  in  5  both  breasts  were  affected.  As  a  rule,  these  tumours 
are  superficially  situated,  but  they  may  be  found  in  any  part  of 
the  gland  or  its  vicinity.  Very  rarely  they  are  placed  altogether 
beneath  it  ;  and  instances  have  been  met  with,  in  which  the 
tumour  has  been  embedded  in  the  pectoral  muscle.  Of  much 
greater  frequency  is  their  occurrence  in  the  peripheral  than 
in  the  central  part  of  the  gland  ;  more  than  three-fourths 
of  the  tumours  under  my 'observation  were  thus  located.  More 
than  half  of  these  peripheral  tumours  were  found  in  the  upper 
segment  of  the  breast,  and  of  the  others,  as  many  occupied  its 
sternal  as  its  axillary  segment ;  while  the  fewest  were  met  with 
in  its  lower  se^jmcnt.^' 


"  Ch.  iv.,  §§  iv.  and  v. 

'*  Of  42  cases  central  8,  peripheral  34.  Of  the  peripheral  tumours  in  the  upf'er 
part  16,  upper  and  sternal  3,  lower  3,  lower  and  axillary  3,  lower  and  sternal  2, 
axillary  4,  sternal  3.  I  have  found  that  14  per  cent,  of  all  fibro-adenomata  of  the 
mammary  region,  originate  from  sequestrated  supernumerary  mammary  structures, 
having  no  connection  with  the  adjacent  gland.     (For  cases  vide  pp.  73-76). 


FIBRO-ADENOMA.  465 

In  5  out  of  50  cases  I  noticed  that  fibro-adenomata  were 
associated  with  lobular  hypertrophy ;  in  two  of  these  cases  both 
breasts  were  thus  affected ;  in  2  the  lobular  enlargement  was  of 
the  same  breast  as  the  tumour,  and  in  one  case  it  was  of  the 
opposite  breast. 

Here  reference  must  be  made  to  the  important  observations  of 
Labbe  and  Coyne/^  who,  as  the  result  of  histological  examina- 
tion, have  shown  that  the  glandular  structures  in  the  vicinity  of 
fibro-adenomata  frequently  exhibit  hyperplastic  changes,  which 
indicate  that  the  morbid  process  that  has  culminated  in  the 
neoplasm,  has  affected  also  the  adjacent  structures  of  the  gland 
in  a  less  degree,  just  as  in  the  case  of  cancer.  It  seems  impos- 
sible to  doubt  but  that  these  hyperplastic  structures  are  the 
source  whence    recurrences   occasionally  arise. 

In  their  gross  structural  outlines  fibro-adenomata  much 
resemble  fibro-sarcomata.  They  are  invariably  encapsuled. 
The  capsule  generally  consists  of  an  external  dense  layer 
of  fibrous  tissue,  and  an  internal  loose  one.  The  laxity  of  the 
latter  is  sometimes  so  considerable,  that  bursa-like  pseudo- 
cysts may  develop  in  connection  with  it.  On  this  peculiarity 
Paget's  theory^^  is  based,  according  to  which  fibro-adenomata 
are  essentially  of  cystic  origin,  the  solid  growths  arising  se- 
condarily from  the  walls  of  the  cysts  into  which  they  grow, 
and  so  eventually  completely  filling  them  to  the  exclusion  of 
their  fluid  contents.  I  cannot  accept  this  view,  because  cysts 
of  this  kind  are  of  very  rare  occurrence,  and  they  are  not 
found  in  association  with  fibro-adenomata  of  small  size.  More- 
over, histological  examination  of  the  capsule  of  these  tumours, 
fails  to  reveal  any  trace  of  an  endothelial  lining  membrane. 

Owing  to  the  laxity  with  which  fibro-adenomata  lie  within 
their  capsule,  and  to  their  complete  detachment  from  the  sur- 
rounding parts,  they  are  exceedingly  mobile,  and  when  pressed 
upon    by  the  finger   they  slip  freely  about ;    hence   also,  after 


'*  "  Traite  des  Tumeurs  Benignes  du  Sein,"  p.  549. 

'""Lectures  on  Surgical  Pathology,"  vol.  ii.,  1853,  p.  70;  z'/a'^  also  Goodhart, 
Ed.  Med.  Jour.,  1872,  p.  1015. 

30 


466 


FIBROMA    AND    FIBRO-ADENOMA. 


opening  the  capsule,  they  can  be  enucleated  with  great  facility. 
Both  cystic  and  non-cystic  forms  of  the  disease  are  met  with, 
but  cysts  are  relatively  of  much  rarer  occurrence  in  fibro- 
adenomata,  than  in  fibro-sarcomata. 

The  non-cystic  varieties  usually  present  as  small,  ovoid  or 
rounded,  lobular  tumours,  which  are  irregularly  bossed.  On 
section  the  cut  surface  assumes  a  convex  shape,  and  there  is 
revealed  a  whitish  fibroid  structure,  in  which  are  embedded  some 
small,   branched,  cleft-like  slits,    which    indicate  the   glandular 


Fig.  66. — Histological  section    of  fibro-adenoma,  showing  incipient  intra-cystic 
vegetations  {Lahbe  and  Coyne). 


structures  (fig.  60).  In  solid  tumours  the  fibrous  stroma  in- 
variably predominates ;  but  in  some  specimens  the  glandular 
elements  are  more  abundant  than  in  others.  The  latter  consist 
of  duct-like  structures  which  are  invariably  lined  with  cells  of 
columnar  type  (fig.  66) ;  they  must  therefore  be  regarded  as 
representing  small  ducts,  and  not  acini  as  usually  stated.  In 
some  specimens  the  stro.ma  consists  of  dense,  wavy,  mature 
fibrous  tissue,  containing  hardly  any  nuclei ;  the  corresponding 
tumours  then  feel  extremely  hard,  and  on  section  they  look  dry 


FIBRO-ADENOMA. 


467 


and  nacreous  ;  in  other  specimens  the  stroma  is  looser  and  con- 
tains numerous  nuclei :  these  forms  are  more  succulent  looking 
and  of  elastic  consistence. 

Cysts  and  intra-cystic  groivths  evolve  in  connection  with  the 
glandular  structures  of  fibro-adenomata,  just  in  the  same  way 
as  they  do  in  connection  with  the  fibro-sarcomata  (figs.  ^'J  and 


Fig.  67. — Histological  section  of  fibro-adenoma,  showing  well-developed  intra- 
cystic  ingrowths,  within  the  largest  of  which  glandular  structures  are  included  {Labhe 
and  Coyne). 


68).  Of  50  fibro-adenomata  consecutively  under  my  observa- 
tion, 13  were  cystic  ;  in  every  case  but  one  the  cysts  were  multi- 
locular,  and  contained  both  solid  and  fluid  contents,  the  former 
predominating  in  5  instances.  The  gross  characters  of  these 
tumours  resemble  those  of  the  cystic  sarcomata,  although  they 
seldom  attain  such  a  large  size, 


468 


FIBROMA    AND    FIBRO-ADENOMA. 


Fibro-adenomata  occasionally  undergo  fatty,  myxomatous, 
telangiectasia  and  calcareous  changes.  Gross'^'  mentions  an 
instance  in  which  a  tumour  of  this  kind  became  partially 
ossified  : — 

The  patient  was  a  lady,  aged  74  ;  and  she  was  free  from  any  return  of  the 
disease  when  last  heard  of,  eight  years  after  its  removal.  The  tumour  was 
3I  cm.  in  diameter,  encapsuled,  very  hard,  rounded  and  nodular.  The 
histological  sections  showed  numerous  myeloid  cells  in  the  stroma,  in  the 
vicinity  of  the  ossification,  but  nothing  characteristic  of  cancer. 


Fig.  68. — An  Intra-cvstic  Ingrowth,  showing  the  Epithelial  Lining  ; 
AND  THE  SUB-JACENT  CONNECTIVE  TissUE  FRAMEWORK  {Coriiil ajid  Ranvier). 
{a)  Fibrous  stroma,     (b)   Connective  tissue  corpuscles.     These   ingrowths  have 
been  denuded  of  their  epithelial  investment.      (c)  An  ingrowth  with  its  epithelial 
investment  entire.      x   300  dia. 

They  may  also  inflame,  and  Jahoda'^  has  reported  an  instance 
of  elimination  by  suppuration. 

The  rate  of  increase  of  the  solid  forms  is  generally  exceed- 
ingly  slow ;    often  after  having  attained    a  certain — not  very 


"  "  Am.  Syst.  Gyn.,"  vol.  ii.,  p.  205, 
'"  Wien.  tned,  IVoch.,  No.  49,  1892. 


FIBRO-ADENOMA.  469 

large — size,  they  remain  almost  stationary  for  long  periods.  Of 
52  cases  consecutively  under  my  observation,  6  had  been  in 
existence  for  periods  varying  from  6  to  34  years.  The  cystic 
forms  often  increase  more  rapidly  and  irregularly.  Rapid 
increase  has  also  occasionally  been  noticed  to  supervene  in  con- 
nection with  pregnancy  and  lactation  ;  but  such  a  sequence  is 
exceptional. 

It  has  been  alleged  by  some  pathologists  that  fibro-adeno- 
mata  occasionally  altogether  disappear  spontaneously.  The 
evidence  hitherto  adduced  as  to  this  is,  however,  far  from  con- 
vincing. Probably  most  of  the  cases  alluded  to,  were  really 
examples  of  lobular  hypertrophy  or  of  localised  chronic 
mastitis  {indiiratio  benignd). 

The  important  question  as  to  the  liability  of  these  tumours 
to  originate  cancer  and  sarcoma,  I  have  elsewhere  discussed  (p. 
310). 

Fibro-adenomata  occasionally  project  considerably  beyond 
the  level  of  the  skin  ;  and  so  eventually  assume  a  pendulous 
form.  Under  these  circumstances  the  overlying  skin  may 
become  purplish,  adherent,  and  eventually  ulcerate,  so  that  the 
tumour  may  fungate,  but  this  very  rarely  happens.  In  a  case 
related  by  Labbe  and  Coyne,^^  a  tumour  of  34  years'  duration, 
was  almost  completely  eliminated  in  this  way.  I  have  seen  a 
chronic  fistula  result  from  the  bursting  of  an  inflamed  cyst 
in  a  tumour  of  this  kind. 

In  5  out  of  50  cases  under  my  observation  there  was  de- 
cided "  irritative  "  enlargement  of  the  adjacent  axillary  glands. 
The  patients  who  bear  these  tumours  generally  appear  to 
be  in  good  health.  Of  35  cases  under  my  observation,  30  were 
well  nourished  (obese  i),  4  moderately  nourished,  and  i  was 
emaciated.  Eleven  of  them  were  pale  and  i  was  sallow. 
Eighteen  were  of  dark,  and  15  of  fair,  complexion.  Of  53 
consecutive  fibro-adenomata,  only  2  were  associated  witii  dis- 
ease of  other  parts  of  the  body ;  of  these  i  patient  was  subject 

''■'  "  Traite  des  Tumeurs  Benignes  du  Sein,"  p.  275. 


470  FIBROMA    AND    FIBRO-ADENOMA. 

to  retroversion  of  the  uterus  and  hysteria,  and  the  other  had 
ovai'ian  cystoma.  Of  the  latter  case  I  append  a  brief  abstract, 
a  remarkable  feature  being,  that  in  both  situations  the  disease 
was  on  the  same  side. 

A  sterile  married  woman,  aged  49,  moderately  nourished  and  with  a 
pronounced  moustache.  Eight  months  ago  she  first  noticed  a  swelling  in 
the  left  iliac  region,  and  three  months  later  oedema  of  the  left  foot  and  leg  ; 
five  months  ago  a  tumour  was  noticed  in  her  left  breast.  Her  mother  died, 
aged  55,  of  cancer  of  the  breast.  On  examination  I  found  a  large  ovarian 
tumour  in  the  left  iliac  region  and  adjacent  parts  ;  and  in  the  upper  and 
axillary  segment  of  the  left  breast,  near  its  periphery,  was  a  hard,  circum- 
scribed, mobile  tumour,  the  size  of  half  a  Tangerine  orange.  Nipple  normal. 
No  enlargement  of  axillary  glands.  Median  laparotomy,  a  thick-walled 
multilocular  cyst  of  left  ovary,  universal  adhesions  and  matting  together 
of  parts,  to  such  an  extent  as  to  prevent  tumour  being  removed.  Cysts 
perforated,  evacuated,  and  drained  ;  edges  of  cyst  wall  stitched  to  the 
external  wound.  Subsequent  recovery  with  great  diminution  of  the 
tumour. 

With  regard  to  the  previous  healtJi,  inquiries  were  made  in 
38  cases  ;  it  had  been  good  in  31  (with  no  serious  illness  since 
childhood  in  icS),  and  indifferent  in  7.  The  following  previous 
diseases  had  been  experienced  : — 

Leucorrhoea  in  3  cases;  typhoid  fever  in  3  cases;  pelvic  cellulitis  (after 
parturition),  in  2  cases  ;  scarlet  fever,  pleurisy,  and  phthisis,  each  in  2 
cases  ;  and  i  case  each  as  follows  :  ulceration  of  the  os  uteri,  hysteria, 
axillary  abscess,  hemiplegia,  bronchitis,  pneumonia  and  rheumatic  fever, 

Fibro-adenomata  never  cause  retraction  of  the  nipple  ;  but 
it  must  be  borne  in  min3  that  in  a  considerable  proportion 
of  these  cases  the  nipple  is  retracted  or  otherwise  malformed, 
owing  to  congenital  defect.  It  happened  thus  in  10  out  of  42 
cases  consecutively  under  my  observation. 

Discharge  from  the  nipple  is  occasionally  associated  with 
these  tumours,  especially  with  the  cystic  forms.  It  is  usually 
serous,  and  when  intra-cystic  vegetations  are  present  it  may  be 
blood-stained. 

As  a  rule  their  presence  causes  little  or  no  pai7i,  but  occa- 
sionally, uneasy  sensations  are  experienced  at  the  menstrual 
periods.  Sometimes,  however,  they  are  associated  with  par- 
oxysmal attacks  of  quasi-neuralgic  pain,  out  of  all  proportion  to 


FIBRO-ADENOAIA. 


471 


the  size  of  the  lesion,  as  in  the  so-called  "  irritable  tumours " 
of  the  breast,  some  of  which  are  fibro-adenomata,  while  others 
are  subcutaneous  fibromata.  A  similar  state  of  things  occa- 
sionally supervenes  in  cancer  and  other  mammary  diseases.  In 
this  connection  it  is  well  to  recollect,  that  the  breast  may 
become  the  seat  of  quasi-neuralgic  attacks  of  pain,  even  in  the 
absence  of  any  appreciable  lesion  whatever. 

The  general  pathology  of  the  fibro-adenomata  presents  many 
points  of  interest. 

The  influence  of  sex  is  very  marked,  for  of  ^y^  consecutive 
tumours  of  this  kind  analysed  by  me,  there  was  only  one  in- 
stance of  the  disease  in  a  male. 

Age  is  also  an  important  factor,  for  in  the  majority  of  cases 
the  disease  begins  in  young  adults,  before  30;  but  it  not  in- 
frequently starts  much  later  in  life.  Of  52  cases  in  which  I 
specially  inquired  with  regard  to  this  factor,  the  earliest  age  at 
which  the  disease  first  appeared  was  15  years,  the  latest  63 
years ;  and  the  mean  age  was  304  years.  The  numbers  for 
each  quinquennial  period  were  as  follows  : — 


15  to  20 

years 

20  „  25 

25  „  30 

30  »  35 

35  »  40 

40  „  45 

45  „  50 

50  »  55 

55  „  60 

60  „  65 

...  in 

II 

cases 

,, 

II 

)> 

,, 

6 

)) 

,, 

5 

5> 

,, 

9 

55 

6 

I 

5) 

case 

„ 

I 

)) 

,, 

I 
I 

)5 

From  this  it  will  be  gathered  that  fibro-adenomata  hardly 
ever  occur  before  puberty,  as  in  the  following  cases  : — 

Bryant^'^  mentions  having  seen  an  instance  in  a  male  child  10  months 
old ;  but  inasmuch  as  fatty,  as  well  as  fibrous  tissue,  formed  part  of  this 
tumour,  it  was  most  probably  a  case  of  "  mduratio  benigna"  due  to 
chronic  mastitis,  for  fatty  tissue  never  enters  into  the  formation  of  fibro- 
adenomata.      Hopkins'^  having    removed    a  fibro-adenoma  the  size  of  a 


-"  "  Diseases  of  the  Breast,"  p.  90. 

'^'  Boston  Med.  atid  Surgical  Journal^  March  26,  18S5,  p.  290. 


472  FIBROMA    AND    FIBRO-ADENOMA. 

chestnut,  from  the  right  breast  of  a  girl  7  years  old,  noticed  that  a  similar 
tumour  soon  afterwards  formed  in  her  left  breast,  which  in  two  and  a-half 
years'  time  attained  nearly  as  large  a  size  as  the  one  removed  from  her 
right  breast.  Histologically  these  tumours  consisted  of  wavy  fibrous  tissue, 
containing  a  few  tubular  glandular  structures. 

Velpeau  --  met  with  a  similar  tumour  in  the  breast  of  a  girl  8  years 
old. 

Patteson-^  has  recorded  two  instances  of  this  disease  in  childhood.  In 
one  case  there  was  a  tumour,  the  size  of  an  almond,  in  the  left  breast  of  a 
girl  13  years  old,  of  ten  months'  duration  ;  and  in  the  other  case  the  right 
breast  of  a  girl,  I2f  years  old.  contained  a  similar  tumour  of  three  months' 
duration.  Both  these  tumours  were  encapsuled ;  and  the  fibro-adenomatous 
nature  of  the  disease  was  determined  by  histological  examination. 

Velpeau  mentions  having  seen  a  fibro-adenoma  that  de- 
veloped as  late  as  the  85th  year  ;  and  Gross  as  late  as  the  74th. 

Civil  State. — Single,  married,  fruitful  and  barren  women  are 
none  of  them  exempt  from  the  formation  of  these  tumours ; 
nevertheless,  as  the  subjoined  figures  show,  they  are  of  more 
frequent  occurrence  in  the  single,  and  in  the  sterile  married, 
than  in  others. 

Of  17  women  thus  affected,  who  had  lived  in  wedlock  many  years,  I 
found  that  4  were  barren  (never  pregnant) ;  of  33  similar  cases,  analysed  by 
Gross,  6  were  barren.  Thus  of  these  50  married  women,  10  were  barren,  or 
20  per  cent.  ;  whereas  in  the  general  community  the  amount  of  absolute 
sterility  amounts  to  only  about  1 1  per  cent. 

Three  of  the  13  fruitful  women  in  my  list  produced  only  a  single  child, 
or  I  in  4"3  ;  whereas  the  ratio  of  one-child  sterility  for  fertile  married 
women  of  the  general  population,  is  only  about  i  in  13. 

Of  52  women  with  these  tum»urs,  under  my  observation,  20  were  married, 
3  widowed,  and  29  were  single. 

Catanienia. — It  has  often  been  pointed  out  that  the  develop- 
ment of  fibro-adenomata  is  not  infrequently  associated  with 
catamenial  irregularities,  &c.  The  following  data  seem  to  sup- 
port this  view ;  they  also  show  that  catamenial  irregularities  are 
much  more  frequently  associated  with  these  tumours,  than  they 
are  with  cancers. 

Of  37  cases  the  catamenia  were  stated  to  have  been  regular  in  31  (scanty 
4,  profuse  2) ;  and  irregular  in  6  (scanty  4,  profuse  2). 


•■-  "  Traite  des  Maladies  du  Sein,  &c. ,"  1854. 
^  Journal  of  Anatomy,  vol.  xxvi.,  1892,  p.  509. 


FIBRO-ADENOMA.  473 

The  earliest  age  at  which  the  catamenial  discharge  first  appeared,  was 
12  years  (there  was  also  a  case  at  I2"5)  ;  the  latest  20 ;  and  the  mean  age  was 
1 5 '4  years. 

The  occupations  followed  by  49  of  the  patients  in  my  list  were 

as  follows  : — 

Of  19  married — housewives  16,  boot  factory  i,  dressmaker  i,  and 
tailoress  i.  Of  2  wzdowed— governess  i  and  needlework  i.  Of  28  single — 
domestic  service  7,  needlework  6,  nurse  (sick)  3,  at  home  3,  laundry  2, 
governess  2,  shop  assistant  2,  and  i  each  as  follows  : — schoolmistress, 
nursery,  milliner. 

Their  birtli  places  were  noted  in  17  cases,  thus  : — 

Nine  were  town  born  (London  6,  Newmarket,  Luton  and  Chatham 
each  i).  Eight  were  coimtry  born  (Norfolk  2,  Northamptonshire,  Lincoln- 
shire, Suffolk,  Middlesex,  Essex  and  near  Edinburgh,  each  i). 

As  to  the  influence  of  previous  injury  or  disease  of  the  breast, 
in  the  causation  of  these  tumours,  it  will  be  gathered  from  the 
subjoined  data,  that  history  of  such  antecedent  occurrences 
was  much  less  frequently  obtained  than  in  the  cancer  cases. 
As  in  the  latter  these  factors  were  shown  to  play  only  a  secon- 
dary part  in  the  causation  of  that  disease,  so,  a  fortiori,  it 
follows  that  in  the  causation  of  fibro-adenomata  their  influence 
is  also  only  subsidiary.     The  data  alluded  to  are  as  follows  : — 

Of  46  cases  I  obtained  history  of  previous  injury  in  7  (blow  6,  pressure 
of  stays  i).  Of  the  same  number  of  cases,  there  was  history  of  previous 
disease  in  4  (sore  nipple  3,  discharge  from  nipple  i). 

Heredity. — That  the  tendency  to  mammary  fibro-adenomata 
may  be  transmitted  by  inheritance,  the  following  cases  prove. 

(i)  In  this  case  a  lady  and  her  three  daughters  all  had  fibro-adenoma  of 
the  breast.  The  patient,  aged  50,  consulted  Broca,^^  on  account  of  a  large 
fibro-adenoma  of  twenty-nine  years'  duration,  in  her  left  breast.  During  this 
long  time  its  increase  had  been  continuous,  but  very  gradual.  When  she 
came  under  observation  the  tumour  had  attained  the  size  of  a  man's  head 
and  was  pendulous  and  pedunculated.  The  skin  over  its  most  dependent 
part  was  congested  and  eroded.  There  was  no  enlargement  of  the  ad- 
jacent lymph  glands.  The  patient  declined  operation  ;  sloughing  of  the 
growth  subsequently  supervened,  of  which  she  died  exhausted,  without  any 
signs  of  malignant  disease  being  manifest.  Broca's  father,  who  had  prac- 
tised medicine  for  many  years  in  the  locality  where  this  lady  lived,  informed 

-'  "  Traite  des  Tumeurs,"  t.  i.,  p.  156. 


474  FIBROMA    AND    FIBRO-ADENOMA. 

him,  that  three  other  members  of  this  family  had  been  under  his  treatment 
for  similar  tumours.  The  eldest  sister  of  the  patient  had  a  tumour  form  in 
her  breast  at  the  age  of  25,  which  in  the  course  of  some  years  attained  the 
size  of  a  big  walnut,  and  subsequently  remained  stationary.  Her  younger 
sister  had  a  similar  tumour  form  in  her  breast  at  the  age  of  20.  Finally, 
the  mother  of  these  three  ladies  died  at  an  advanced  age,  having  in  her 
breast  a  tumour  the  size  of  a  fowl's  egg,  which  first  formed  when  she  was 
quite  a  young  woman.  This  lady  had  no  other  children.  It  is  remarkable 
that  all  the  three,  at  about  the  same  age,  became  subject  to  the  same 
disease. 

(2)  In  a  case  by  Puis,-''  a  woman  and  her  daughter,  each  had  /wo 
cystic  fibro-adenomata,  in  the  le//  breast. 

Instances  of  the  hereditary  transmission  of  mammary  fibro- 
adenomata  are,  however,  relatively  of  much  less  frequent  occur- 
rence than  the  hereditary  transmission  of  cancer. 

Thus  of  38  cases  of  fibro-adenoma  in  my  list,  there  was  history  of  similar 
disease  in  but  three  families,  or  in  7*9  per  cent.  ;  whereas  there  was  history 
of  similar  disease  in  24*2  per  cent,  of  the  cancer  families.  Similarly  if  we 
restrict  the  inquiry  only  to  direct  inheritance,  it  appears  that  of  38  patients 
with  fibro-adenoma,  there  was  only  one  instance  of  direct  transmission  of 
the  disease  from  mother  to  daughter,  or  2 '6  per  cent. ;  whereas  in  the  cancer 
cases  there  was  history  of  direct  transmission  in  about  8  per  cent. 

On  the  other  hand,  among  the  relatives  of  patients  with 
mammary  fibro-adenoma,  I  have  found  a  greater  proportion  of 
other  non-malignant  neoplasms  to  exist,  than  among  the  relatives 
of  the  cancer  patients. 

Thus  of  38  patients  with  fibro-adenoma,  two  knew  of  instances  of  the 
occurrence  among  their  relatives  of  other  non-malignant  neoplasms,  or  5'2 
percent.  ;  whereas  of  the  breast  cancer  patients,  only  v^  per  cent,  knew 
of  the  occurrence  of  non-malignant  neoplasms  in  their  families. 

Another  point  to  which  I  wish  to  call  attention  is,  that  of 
38  patients  with  fibro-adenoma,  there  was  family  history  of 
cancer  in  5,  or  in  I3*i  per  cent.,  and  in  2  of  the  cases  the  breast 
was  the  seat  of  the  disease. 

Hutchinson^*'  has  recorded  an  instance  of  mammary  fibro- 
adenoma hereditary  in  three  generations,  complicated  with 
scirrhous  cancer  in  one  of  them. 


Arcli.  f.  path.  Anat.,  Bd.  xciv. ,  S.  455. 

Archives  of  Surgery,  jd^nnaLYy,  1891,  p.  261,  Plate  xxiv. 


FIBRO-ADENOMA. 


475 


Twenty  years  ago  Mrs.  H 's  breast  was  removed  for  a  rather  large 

fibro-adenoma.  She  then  was  50  years  old.  She  is  still  alive  and  well. 
Lately  one  of  her  daughters,  aged  40,  came  under  Hutchinson's  care  for 
what  seemed  to  be  scirrhous  cancer  of  the  breast.  She  had  noticed  a  small 
tumour  in  her  breast  ever  since  childhood.  On  examination  of  the  part 
after  removal,  it  was  found  to  contain  an  encapsuled  fibro-adenoma,  the 
size  of  a  marble,  beneath  which  there  was  an  ill-defined  area  of  hard 
cancer.  The  fibro-adenoma  was  not  itself  infiltrated.  There  was  subse- 
quent recurrence  in  the  axillary  glands.  One  of  this  woman's  daughters 
now  has  fibro-adenoma  of  the  breast. 

It  will  be  gathered  from  the  foregoing,  that  although  in  the 
transmission  of  neoplasms  by  heredity,  the  original  morbid  type 
is  usually  preserved,  yet  instances  do  occur  in  which  in  the 
course  of  transmission  the  type  is  charged,  malignant  neoplasms 
being  transmuted  into  non-malignant  ones  and  vice  versa ;  and 
cases  are  even  met  with  in  which  varieties  of  these  types  are 
transmuted  inter  se.  Such  considerations  seem  to  support 
Verneuil's  theory,  according  to  which  the  different  kinds  of 
neoplasms  are  but  varied  manifestations  of  a  certain  general 
predisposition,  the  so-called  neoplastic  diathesis,  as  to  the 
nature  of  which  he  leaves  us  in  doubt.  That  a  pre-disposition 
to  cancer  does  exist  I  have  elsewhere  shown  (ch.  x.  §  iv.) ;  and 
I  have  there  indicated  that  it  is  closely  allied  to  the  tuber- 
cular predisposition,  of  which  it  is  probably  but  a  diluted  form. 
The  subjoined  analysis  of  the  family  history  of  patients  with 
fibro-adenoma,  shows  that  to  this  disease,  a  similar  predisposi- 
tion also  exists. 

In  further  illustration  of  the  subject  I  append  the  following 
Analysis  of  the  Family  History  of  38  patients  with  mammary 
fibro-adenoma. 


The  fathers  : — Of  27  cases  in  which  inquiries  were   made,  in    16   the 
fathers  were  dead,  and  in  1 1  still  alive. 
The  causes  of  death  were  as  follows  : — 
Phthisis 
Bronchitis     ... 


Accident 
Pneumonia  ... 
Cancer  of  stomach 
Alcoholism    . . . 


2      „ 
I  case 


476 


FIBROMA    AND    FIBRO-ADENOMA. 


Apoplexy 
Small-pox     ... 
Carbuncle  (back  of  neck) 


in  I  case 
I 


)> 


)) 


Total     ...  ...        13  cases 

In  3  cases  the  causes  of  death  were  unknown. 

The  average  age  of  the  fathers  at  deaths  in  16  cases,  was  55*4  years  ;  the 
oldest  75,  the  youngest  27. 

Of  the  II  fathers  still  alive,  i  was  hemiplegic,  i  bronchitic,  and  i  subject 
to  gravel  ;  the  others  were  in  good  health. 

Their  average  age  62"3  years  ;  the  oldest  75,  the  youngest  50. 
T\\&  mothers : — Of  30  cases  in  which  inquiries  were  made,   in  20  the 
mothers  were  dead,  and  in  10  still  alive  and  well. 
The  causes  0/  death  were  as  follows  : — 

Phthisis         ...  ...  ...  ...  ...     in  4  cases 

Apoplexy       ...  ...  ...  ...  ...      „  3      „ 


Heart  disease 

Cancer  (breast  i,  uterus  i) 

Childbed       ... 

Insanity 

Accident 

Internal  tumour 

Bronchitis     ... 

Small-pox     ... 


Total     ...  ...        19  cases 

In  I  case  the  cause  of  death  was  unknoivn. 

The  average  age  of  the  mothers  at  death  (in  19  cases)  was  45*2  years  ; 
the  oldest  68  ;  the  youngest  24. 

The  average  age  of  the  mothers  still  alive  (in  6  cases)  was  57  years  ; 
the  oldest  64  ;  the  youngest  45. 

Consanguinity  in  the  Parents: — As  to  this,  inquiries  were  made  in  19 
cases  with  negative  results. 

The  Patietifs  Brothers  and  Sisters  :  —  In  12  families  the  following  causes 
of  death  were  noted  among  the  adults  : — 


Insanity     ... 
Bronchitis... 

...                    ...        Ill   ^   laiuiiic 

„    -           „ 
,,    2           ,, 

Alcoholism 
Heart  disease 

„   I  family 

Fever 

Childbed 

„   I        „ 
,,   I        „ 

Peritonitis 

...              ...      ))   »        )) 

Typhoid  Fever 

,,  I        „ 

The  number  of  jnembers  in  each  family  was  noted  in  27  cases.     The 
smallest  family  consisted  of  2  ;  the  largest  of  16  ;  the  average  of  7'2. 

The  Occurrence  of  Tutnour : — Of  38  cases,  there  was  history  of  tumour 


FIBRO-ADENOMA. 


477 


in   7  families  (i8"4  per  cent.).      The  relatives   affected,    the    seats    of  the 
disease,  &c.,  were  as  follows  : — 

(i  and  2)  Sister  with  adenoma  oi  breast  (in  2  families). 

(3)  Mother  with  adenoma  oi  breast  (in  i  family). 

(4)  Maternal  grandmother  with  lipo)na  Q){  abdominal  wall  (in  i  family). 

(5)  Female  cousin  on  father's  side  with  lipoma  of  shoulder  (in  i  family). 

(6)  Maternal  grandmother  with  sebaceous  cysts  oi  scalp  (in  i  family).  In 
this  case  the  patient's  mother  died  of  cancer  of  the  breast. 

(7)  Mother  died  of  internal  tumour  (in  i  family). 

The  Occurrence  of  Cancer : — Of  38  cases,  there  was  history  of  ca7icer  in 
5  families  (i3'i  per  cent.). 

The  relatives  thus  affected,  and  the  seats  of  the  disease,  were  as 
follows  : — 

(i)  Father  died  of  cancer  oi  stomach,  and  his  sister  of  cancer  of  breast. 

(2)  Mother  died  of  cancer  of  breast  (her  mother  had  sebaceous  cysts  of 
scalp). 

(3)  Mother  died  of  cancer  of  uterus. 

(4)  Maternal  grandmother  died  of  cancer  oi  breast. 

(5)  Maternal  grandmother  died  oi  internal  cancer. 

The  Occurrence  of  Phthisis  : — Of  25  families,  in  10  (40  per  cent.)  one  or 
more  relatives  had  died  of  phthisis  ;  in  6  of  these  families  more  than  a 
single  member  had  thus  succumbed. 

The  relatives  affected  may  be  classed  as  follows  : — 

Fathers     ... 

Father's  brothers    ... 

Mothers    ... 

Mother's  brothers  and  sisters 

Mother's  father 

Patient's  brothers  and  sisters 

The  Combi7iatio7i  of  Phthisis  and  Cancer: — Of  38  families,  this  was 
noted  in  2.     Thus — 

(i)  Mother  died  of  cancer  of  uterus  ;  and  her  father  died  of  phthisis. 

(2)  Maternal  grandmother  died  of  internal  cancer  ;  and  patient's  father 
died  of  phthisis. 

The  Combinatio7i  of  Phthisis  and  Tumour  i—Oi  38  families,  this  was 
noted  in  2. 

(i)  Female  cousin  on  father's  side  had  lipoma  of  shoulder  ;  patient's 
father  and  2  of  his  brothers  and  sisters  died  of  phthisis. 

(2)  Mother  had  adenoma  of  breast ;  her  sister  and  patient's  sister  were 
phthisical. 

The  Occurrence  of  htsanity : — Of  10  families,  there  was  history  of  in- 
sanity in  2  ;  in  I  of  these  the  patient's  mother  and  her  brother  died  insane, 
and  in  the  other  the  patient's  mother  died  insane. 

The  diagnosis  of  fibro-adenomata,  as  a  rule,  is  not  a  difficult 
matter. 

In  their  general  features  certain  sarcomata  much  resemble- 


..     in  3 

families 

■■      »  2 

■)■> 

,  3 

It 

,  4 
,  5 

11 
family 
families 

478  FIBROMA    AND    FIBRO-ADENOMA. 

them  ;  but  these  tumours  are  seldom  so  mobile  as  the  adeno- 
mata ;  their  increase  is  more  rapid,  and  they  generally  occur  in 
older  subjects.  From  villous  papilloniata  they  may  be  differ- 
entiated by  having  regard  to  the  fact,  that  the  tumours  pro- 
duced by  these  growths'  usually  fluctuate  and  are  central  in 
position,  being  disposed  in  a  radiating  manner  from  the  nipple  ; 
moreover  they  are  generally  accompanied  by  a  blood-stained 
serous  discharge  from  the  nipple.  From  tubular  cancers  with- 
out lymph  gland  enlargement,  they  may  be  known  by  the 
irregularity  in  the  shape  of  the  tumours  in  these  cases,  by 
the  frequent  presence  of  small  nodular  cysts,  and  by  the  com- 
paratively advanced  age  of  the  patients  thus  affected.  Certain 
hard  cancers,  when  small,  circumscribed  and  unaccompanied 
by  lymph  gland  enlargement,  occasionally  resemble  fibro- 
adenomata ;  on  careful  examination  they  will  be  found  to  be 
more  incorporated  with  the  gland,  and  above  all,  to  be  less 
mobile,  and  they  generally  occur  in  persons  of  more  advanced 
ao-e  than  those  who  bear  fibro-adenomata.  Some  forms  of 
lobular  hypertrophy  may  also  mimic  fibro-adenomata,  but  in 
these  cases  the  tumours  are  obviously  connected  with  the  gland  ; 
they  are  less  circumscribed  than  fibro-adenomata,  and  more- 
over, they  are  often  multiple.  Chronic  inflamviatory  sivellings 
("  induratio  benigna ")  may  simulate  these  growths,  but  they 
are  seldom  so  circumscribed  and  mobile.  The  same  applies 
to  certain  localised  tubercular  and  syphilitic  lesions  occa- 
sionally met  with  in  the  breast.  The  only  other  lesions  likely 
to  be  mistaken  for  fibro-adenoma  are  small  tense  cysts  and 
chronic  abscesses,  as  to  the  differential  diagnosis  of  which  nothing 
further  need  be  said. 

Under  the  name  of  diffuse  fibroma  Virchow^^  has  described 
diseases  of  the  breast  which  are  really  examples  of  the  fibrous 
form  of  hypertrophy,  and  of  diffuse  chronic  mastitis,  rather 
than  of  true  neoplastic  action.  It  is  evident  also  that  the  so- 
called  '^ plexifonn  fibroma  "'^^  {mdi\did\Q  noueuse)  is  a  periductal 

•"  "  Path,  (ies  Tunieurs,"  t.  i.,  pp.  318  and  325. 

■"  Nordmann,  Arch.  f.  path.  Anat.,  Bd.  cxxvii. ,  S.  338. 


FTP.RO-ADENOMA.  479 

inflammatory  sclerosis,  and  not  a  form  of  true  neoplasia.  In 
this  connection  mention  may  be  made  of  the  attempt  made 
by  Delbet^^  to  account  for  fibro-adenomata,  as  localised  peri- 
ductal scleroses,  consequent  on  chronic  inflammation,  in  support 
of  which  I  think  there  is  very  little  to  be  said. 

Treatment. — The  only  treatment  that  I  can  recommend  for 
mammary  fibro-adenomata,  is  their  complete  removal  by  opera- 
tion ;  and  the  sooner  this  is  done  the  better.  It  is  a  vain  delu- 
sion to  expect  their  resolution  either  spontaneously,  or  as  the 
result  of  local  applications  or  internal  medicaments.  Com- 
pression, electrolysis,  &c.,  are  equally  futile.  Removal  by 
caustics  is  out  of  the  question  on  account  of  the  deformity 
thus  produced.  Nothing,  therefore,  remains  but  the  knife. 
For  small,  mobile,  chronic  tumours,  enucleation  is  the  pro- 
cedure usually  adopted.  The  patient  being  anaesthetised,  the 
part  of  the  breast  in  which  the  tumour  lies  is  seized  between 
the  fingers  and  thumb  of  the  left  hand,  so  as  to  make  the 
tumour  project,  with  the  skin  tightly  stretched  over  it.  An 
incision,  radiating  from  the  nipple,  is  then  made  through  the 
skin,  &c.,  over  the  tumour,  right  down  to  the  latter,  which — on 
division  of  its  capsule — at  once  projects  from  the  wound,  when 
it  is  seized  by  an  assistant  with  vulsellum  forceps,  and  removed 
with  a  few  touches  of  the  knife.  As  a  rule  there  is  no  haemor- 
rhage worth  mentioning,  but  a  vessel  or  two  may  require 
ligation.  The  wound  is  then  irrigated  with  carbolic  lotion, 
closed  with  deep  and  superficial  sutures,  and  dressed  with  anti- 
septic appliances.  The  upper  limb  should  for  a  time  be  kept 
in  a  sling.  This  operation  is  not,  as  a  rule,  attended  by  any 
danger  ;  the  wound  generally  closes  by  first  intention,  and  the 
only  mark  eventually  left  is  a  small  linear  scar. 

Of  39  consecutive  ho.spital  operations  of  this  kind  under  my 
observation,  not  a  single  one  was  attended  with  any  subsequent 
untoward  event ;  there  was  no  instance  of  the  supervention  of 
erysipelas  or  other  septic  disease.     This  immunity  from  septic 

"^  Duplay  and  Reclus'  "  Traite  de  Chirurgie,"  t.  vi.,  p.  259,  &c. 


480  FIBROMA    AND    FIBRO-ADENOMA. 

disease  contrasts  very  favourably  with  the  results  obtained 
before  antiseptics  came  in  vogue ;  for  of  60  hospital  operations 
of  this  kind  done  by  Velpeau,^°  in  10  the  wounds  were  sub- 
sequently attacked  by  erysipelas,  in  2  by  hospital  gangrene,  and 
in  several  by  diffuse  suppuration. 

An  ingenious  proceeding  has  been  devised  by  Gaillard 
Thomas,^^  with  the  object'  of  concealing  the  scar  resulting  from 
the  operation.  It  is  a  modification  of  the  ancient  operation  for 
gynaecomastia.  He  makes  his  incision  along  the  fold  uniting 
the  lower  hemisphere  of  the  bosom  with  the  thorax,  and  having 
separated  the  base  of  the  gland  from  the  pectoral  muscle,  he 
removes  the  tumour  by  incision  through  the  under  surface  of 
the  gland.  Jamieson,^^  Hayward'^^  and  others,  have  obtained 
satisfactory  results  from  this  operation. 

In  the  great  majority  of  cases  the  simple  enucleation  of  fibro- 
adenomata  suffices  for  their  permanent  cure.  Occasionally,  how- 
ever, after  a  certain  time,  there  is  return  of  the  disease,  either 
locally,  in  some  other  part  of  the  same  breast,  or  in  the  opposite 
breast.  Of  39  consecutive  enucleations  under  my  observation, 
there  was  only  a  single  instance  of  local  recurrence  ;  but,  accord- 
ing to  Gross,  recurrence  is  met  with  on  the  average  once  in  25 
cases.  As  to  the  explanation  of  such  local  recurrences,  the  very 
complete  encapsulation  of  fibro-adenomata  quite  precludes  the 
possibility  of  their  being  ascribed  to  portions  of  the  primary 
tumour  left  behind  at  the  operation.  It  seems  certain  that  most 
cases  are  veritable  repullulatiotis,  due  to  fresh  outbreaks  of  the 
disease  in  adjacent  hyperplastic  glandular  structures.  In  some 
instances  it  may  be,  that  at  the  time  of  the  first  operation  a 
second  tumour  already  existed,  which,  after  removal  of  the 
main  one,  has  subsequently  grown  into  prominence. 

The  following  example  of  recurrence  has  come  under  my 
notice. 


^  "  Traite  des  Maladies  du  Sein,"  &c.,  1854,  p.  420. 

="  New  York  Medical  Journal,  April,  1882,  [).  337. 

^'-  Brilish  Medical  Journal,  vol.  i.,  1888,  p.  1216,  also  vol.  ii.,  1893. 

^  British  Medical  Journal,  vol.  i.,  1889,  p.  410. 


FIBRO-ADENOMA.  481 

A  healthy  looking,  single  woman,  aged  22,  who  was  a  schoolmistress, 
with  a  firm,  elastic,  freely  movable  nodule — the  size  of  a  large  filbert — 
in  her  left  breast,  close  to  a  small  scar,  resulting  from  the  enucleation  of 
a  similar  tumour,  eighteen  months  previously.  It  was  first  noticed,  as  a  pea- 
sized  tumour,  fifteen  months  ago.  The  axillary  glands  were  normal.  The 
tumour  was  dissected  out.  Microscopically  and  macroscopically  examined, 
it  presented  the  appearance  of  ordinary  fibro-adenoma.  The  wound  com- 
pletely healed  in  the  course  of  a  few  days.  Three  and  a-half  months 
later  she  again  came  under  observation  with  a  similar  tumour  in  the  same 
situation,  which  was  again  excised. 

Rosenstirn^'*  has  reported  the  following: — 

From  the /^/ breast  of  a  multipara,  aged  45,  afibro-adenomaof  one  year's 
duration  was  enucleated.  Five  years  later,  a  similar  tumour  of  six  months' 
duration  was  enucleated  from  the  rio;ht  breast.  A  year  after  the  last 
operation,  a  fresh  tumour  having  formed  in  the  left  breast,  was  excised. 
Eighteen  months  later,  another  tumour  was  excised  from  the  same  breast, 
yet  another  four  years  later ;  and  finally  still  another  three  years  later.  From 
the  7'icrht  breast  a  second  tumour  was  removed  about  two  years  after  the 
first  operation  ;  and  another  seven  years  later.  All  these  tumours  were  in 
their  histological  and  other  characters  just  like  the  ordinary  fibro-adenoma. 
Velpeau^^  relates  that  a  lady  from  whose  breast  he  had  removed  a  fibro- 
adenoma ten  years  previously,  then  applied  to  him  with  another  similar 
tumour  in  the  same  situation,  which  he  also  excised. 

Considerations  of  this  kind  have  induced  many  surgeons  to 
doubt  the  efficacy  of  the  ordinary  enucleation,  as  a  means  for 
removing  these  tumours.  Instead,  they  recommend  that  the 
disease  should  be  got  rid  of  by  partial  amputation  of  the  breast, 
the  tumour  and  its  capsule,  together  with  a  wedge-shaped  zone 
of  the  surrounding  tissues,  being  removed  en  masse.  Where 
aesthetic  considerations  are  not  of  paramount  importance,  this 
operation  is  clearly  indicated,  especially  for  tumours  that  have 
attained  a  larger  size  than  a  walnut.  For  tumours  of  still 
larger  dimensions,  bigger  than  a  hen's  Q'gg,  for  instance,  total 
amputation  of  the  breast  is  the  preferable  operation  ;  since  these 
large  tumours,  oftener  than  others,  eventually  prove  to  be  of  a 
sarcomatous  nature. 

A  few  instances  have  been  recorded  in  which  within  a 
comparatively  short  time  after  the  removal   of   fibro-adenoma, 

=**  Arch.  f.  path.  Anat.,  Bd.  Ivii.,  S.  166. 
^'^  "  Traite  des  Maladies  du  Sein,"  p.  350. 

3t 


482  FIBROMA    AND    FIBRO-ADENOMA. 

the  same  breast  has  become  the  seat  of  cancer  f^  and  Pick^^ 
has  related  a  case  in  which  after  removal  of  such  a  tumour 
from  the  breast,  cancer  developed  in  the  axilla. 

In  the  event  of  operative  treatment  being  refused,  the  best 
thing  is  to  cover  the  tumour  with  a  belladonna  plaster ;  or  to 
paint  the  part  with  extract  of  belladonna  in  glycerine  (to  which 
an  equal  part  of  ung.  plwnbi  iodidi  may  be  added),  and  cover 
it  with  cotton  wool,  kept  in  place  by  strapping. 


■""  Erichsen,  Lancet,  Febiuuiy  14,  1852. 

^'  Trans.  Path.  Soc.  Land.,  vol.  x\.,  p.  347. 


483 


CHAPTER   XIX. 
Lipoma,  Chondroma,  Osteoma,  Angioma,  Papilloma,  &c. 


S    1 . Lipoma. 

I  HAVE  previously  called  attention  to  the  remarkable  immu- 
nity from  neoplasia  of  the  fibrous  tissue  of  the  breast,  other 
than  that  in  the  immediate  vicinity  of  the  small  ducts  ;  its  fatty 
tissue,  which  is  never  found  in  close  proximity  to  these  struc- 
tures, is  still  more  rarely  affected  in  this  way.  Of  2,397  con- 
secutive neoplasms  of  the  female  breast  analysed  by  me,  there 
was  not  a  single  instance  in  which  the  disease  originated  from 
its  fatty  tissue.  Circumscribed  lipomata  do,  however,  occasion- 
ally arise  in  the  breast  and  its  vicinity  ;  and  very  exceptionally 
the  whole  of  the  fatty  envelope  of  the  gland  becomes  overgrown 
(so-called  diffuse  lipoma).  Some  of  these  cases  are  probably 
instances  of  hypertrophy,  in  which  the  stress  of  the  disease 
has  fallen  on  the  fatty  capsule.^  In  other  instances  over- 
growth of  the  fatty  envelope  of  the  gland  is  associated  with 
circulatory  disturbances  due  to  cancer,  or  chronic  mastitis^ 
(so-called  capsular  lipoma).  In  this  category  I  think  Roper's^ 
case  of  mammary  lipomatosis  ought  to  be  included. 

Here  there  was  a  large  pendulous  tumour  of  58  years'  duration.  The 
woman  who  bore  it  died  at  the  age  of  87.  During  her  lifetime  it  had  been 
taken  for  fibro-adenoma  ;  but  upon  cutting  into  the  tumour  after  death,  it 


'  For  cases,  see  pp.  89  and  94. 

"  See  p.  228. 

=*  Birkett  in  Holmes'  "System  of  Surgery,'  vol.  iii.,  1883,  p.  449. 


484  LIPOMA,    CHONDROMA,    OSTEOMA,    ETC. 

was  found  to  consist  of  a  mass  of  fatty  tissue,  enclosing  an  irregularly 
shaped  piece  of  bone  at  its  centre.  I  should  interpret  these  appearances 
as  the  result  of  "quiet  necrosis,"  with  lipomatosis  of  the  congested  and 
chronically  inflamed  surrounding  tissues. 

Here  also  the  case  mentioned  by  Brodie^  of  "  chronic  mammary 
tumour  "  surrounded  by  a  large  mass  of  fat  situated  behind  the  breast  prob- 
ably belongs  ;  as  also  the  so-called  multiple  mammary  lipomata  signalised 
by  Reclus.-'' 

When  they  do  occur  mammary  h'pomata  almost  invariably 

arise  from   the    para-mammary   fatty   tissue  ;    I    know  of  only 

three  recorded  examples  of  intra-mammary  lipoma. 

In  Koehler's"  case,  a  large  fibro-lipoma  was  removed  from  within  the 
gland.  A  similar  case  has  been  reported  by  Begouin.^  The  other  case  is 
by  Astley  Cooper  f  he  describes  processes  of  the  tumour  as  being  inter- 
spersed between  the  glandular  lobes. 

The  majority  of  para-mammary  lipomata  arise  in  the  sub- 
cutaneous fatty  tissue  over  the  front  of  the  breast ;  in  this  situa- 
tion they  seldom  attain  a  large  size  ;  on  the  other  hand,  the 
tumours  of  retro-mammary  origin  often  attain  immense  pro- 
portions. The  following  are  some  good  examples  of  this 
form  of  fatty  tumour. 

(i)  A  multipara,  aged  34, came  under  Billroth's*  observation  with  colossal 
enlargement  of  the  right  breast,  which  reached  as  low  down  as  the  pelvis. 
Its  greatest  length  was  43  cm.  The  nipple  and  areola  were  situated  at  the 
lowest  part  of  the  swelling  ;  and  in  this  situation  the  skin  was  of  a  dark 
purple  colour  from  congestion.  The  diseased  part  felt  soft  and  elastic, 
with  here  and  there  firmer  knots  and  lobulations.  The  superficial  veins 
were  unduly  obvious.  There  was  no  enlargement  of  the  axillary  glands  ; 
the  patient  was  moderately  nourished  and  in  fairly  good  health.  She  said 
she  first  noticed  some  enlargement  at  the  upper  part  of  the  breast  six  years 
ago,  which  subsequently  gradually  increased.  Her  last  child  was  born 
nearly  two  years  ago.  The  left  breast  was  normal.  It  was  thought  to  be  a 
case  of  hypertrophy  or  cysto-sarcoma.  After  amputation  of  the  part  it 
proved  to  be  a  gigantic  retro-mammary  lipoma.  The  mammary  gland 
flattened  from  pressure  was  found  in  the  vicinity  of  the  nipple.  Unfortu- 
nately the  tumour  was  not  weighed.     The  patient  was  soon  convalescent. 


"  Lectures  on  Pathology  and  .Surgery,"  p.  281. 
C/t'n.  Chir.y  p.  414. 

CharitS  An7iale7i,  Bd.  xiii.,  1888,  S.  531. 
yottrnal  de  Mid.  de  Bordeaux,  Feb.  25,  1892. 
"  Illustrations  of  Diseases  of  the  Breast,"  p.  68. 
Deutsche  Chi)-.,  Lief.  xli. ,  S.  45. 


LIPOMA.  485 

(2)  In  a  case  by  Bryk'"  a  large  fibro-lipoma,  weighing  12  lbs.,  was 
removed  from  behind  the  right  breast  of  a  woman  aged  49,  who  shortly 
afterwards  died  of  septicaemia.  At  the  necropsy  she  was  found  also  to  have 
a  lipoma  of  the  ctecum. 

(3)  In  a  similar  case  by  Brodie,"  a  lady  came  under  treatmenffor  what 
appeared  to  be  a  tumour  of  the  breast.  She  was  the  wife  of  a  medical 
practitioner  ;  and  she  had  the  opinions  of  three  or  four  of  the  leading 
surgeons  of  the  day  on  her  case  ;  but  they  could  not  agree  as  to  its  nature. 
It  was  decided  to  cut  down  on  the  tumour,  and  on  this  being  done,  it  was 
found  to  be  a  large  lipoma,  situated  behind  the  breast  ;  which,  being  of  large 
size,  had  been  lifted  up  by  the  tumour,  and  seemed  itself  to  be  enlarged. 

(4)  A  delicate  young  woman,  under  Velpeau,^^  had  a  very  large  pendu- 
lous tumour  of  this  kind,  growing  from  her  right  breast.  When  she  stood 
up  it  reached  as  low  down  as  the  iliac  crest.  It  was  of  three  and  a-half 
years'  duration,  and  its  situation  was  behind  the  breast.  After  removal  it 
weighed  \\  lbs.  ;  and  it  was  composed  only  of  adipose  tissue. 

As  examples  of  subcutaneous  lipoma  the  following  cases 
will   suffice  : — 

(i)  An  unmarried  servant,  aged  30,  came  under  my  observation  with  a 
fatty  tumour — the  size  and  shape  of  a  lady's  watch — at  the  upper  and  outer 
part  of  the  periphery  of  the  left  breast.  It  was  of  two  years'  duration.  She 
was  soon  convalescent,  after  its  excision. 

(2)  In  a  case  under  Bryant's  care  ^^  a  lobulated  fatty  tumour  the  size  of 
half  an  orange  was  removed  from  over  the  upper  part  of  the  left  breast  of 
a  multipara,  aged  50.     It  was  of  five  years'  growth. 

(3)  A  dressmaker,  aged  45,  the  mother  of  five  children,  came  to  Velpeau  ^^ 
on  account  of  tumour  of  several  years'  duration  of  her  left  breast.  On 
examination  there  was  found  a  large,  irregularly-shaped,  lobular  tumour, 
the  size  of  two  fists,  over  which  the  skin  was  reddened.  Some  parts  of  it 
felt  quite  soft,  others  rather  hard.  It  was  dissected  out  ;  and  proved  to 
be  a  lobulated  fatty  tumour,  which  appeared  to  have  been  situated  over 
the  front  of  the  breast. 

(4)  In  another  case  by  the  same  surgeon,  a  stout,  healthy-looking 
woman,  aged  30,  had  a  tumour  the  size  of  a  hen's  ^%g,  in  the  lower  and 
outer  part  of  her  left  breast.  It  was  of  several  years'  duration.  It  felt 
soft,  bossy,  and  subcutaneous.  Velpeau  took  it  for  a  cyst,  believing  fluctua- 
tion certain.  It  was  punctured,  but  no  fluid  escaped.  On  exploration  with 
the  knife;  a  lobulated  fatty  tumour  was  exposed  and  removed. 


Arch.  f.  klin.  Chir.,  Bd.  xvii.,  S.  576. 

"  Lectures  on  Pathology  and  Surgery,"  1846,  p.  271. 

"  Traite  des  Maladies  du  Sein,  &c.,"  p.  250. 

"  Diseases  of  the  Breast,"  p.  348. 

"  Traile  des  Maladies  du  Sein,  &.C."  Paris,  1854,  p.  248. 


486  LIPOiMA,    CHONDROMA,    OSTEOMA,    ETC. 

^     1 1. Chondroma,  Osteoma,  &c. 

It  has  been  pointed  out  by  several  observers  (Hacker,^^ 
Rindfleisch,^''  &c.),  that  in  the  stroma  of  the  otherwise  normal 
breast,  small  cartilaginous  and  even  truly  osseous  nodules  may 
occasionally  be  found.  The  most  feasible  explanation  of  the 
presence  of  these  heterotopic  structures  in  this  situation,  is  that 
which  ascribes  their  origin  to  sequestrations  of  small  portions 
of  the  matrix  of  the  evolving  thoracic  skeleton,  at  an  early 
stage  of  development.  The  cartilaginous  and  osseous  structures 
occasionally  found  associated  with  cancerous  and  sarcomatous 
neoplasms  doubtlessly  spring  from  this  source.  It  seems 
certain  that  the  various  cartilaginous  and  ossifying  growths 
we  now  have  to  study,  which  are  great  rarities,  have  a  similar 
origin.  In  the  mammae  of  bitches,  as  pointed  out  by  Virchow 
and  Creighton,  tumours  containing  cartilage  are  of  frequent 
occurrence.  Although  several  cases  of  innocent  cartilaginous 
ossifying  tumours  of  the  breast  have  been  recorded,  most  patho- 
logists still  hesitate  to  admit  the  existence  of  true  enchondroma 
and  osteoma  of  this  part.  Subjoined  are  brief  abstracts  of  the 
chief  cases  of  this  kind  hitherto  recorded. 

(i)  According  to  Wacker,"'  there  is  in  the  Pathological  Institute  of 
Rostock  a  specimen  of  true  mammary  chondroma,  the  size  of  a  hen's  egg, 
composed  of  hyaUne  and  fibrous  cartilage,  interspersed  with  calcareous 
deposits. 

(2)  Lange'*  removed  from  the  breast  of  a  woman,  aged  5 1,  a  tumour  com- 
posed of  a  number  of  rounded  lobular  masses,  united  together  by  strong 
bands  of  fibrous  tissue.  Histologically  these  consisted  mainly  of  hyaline 
cartilage,  partially  ossified. 

(3)  Cruveilhier'-'  says  :  "  I  have  seen  in  the  substance,  and  on  the  surface 
of  the  mammary  gland,  enchondromas  which  presented  all  the  clinical 
characters  of  fibroid  masses,  and  all  the  pathological  characters  of  car- 
tilaginous tissue."  He  then  refers  to  a  cartilaginous  tumour  that  had  been 
removed  from  the  breast  by  Nelaton,  which  he  says  was  firm  and  resistant, 
and  had  all  the  characters — macroscopical  and  microscopical — of  cartilage. 


'*  ArcA.  f.  klin.  C/iir.,  t.  xxvii.,  S.  614. 

^'^  Path.  Anat.,  §  601. 

"  "  Inaug.  Diss.,"  Rostock,  1884,  cited  by  Gross. 

'"  Medical  Record^  vol.  ii.,  1881,  p.  161. 

'•'  "Traite  d'Anat.  Path.,"  t.  iii.,  p.  824. 


CHONDROMA,    OSTEOMA.  487 

(4)  In  Astley  Cooper's  case,-"  a  hard,  lobulated  tumour- -the  size  of  a 
duck's  egg — of  fourteen  years'  duration,  was  removed  from  the  breast  of  a 
woman  aged  32.  Her  general  health  was  good,  and  the  axillary  glands 
were  normal.  On  examination  of  the  tumour,  "the  larger  part  of  it  had  the 
appearance  of  that  cartilage  which  supplies  the  place  of  bone  in  the  young 
subject  ;  the  remaining  part  was  ossified." 

(5)  Among  instances  of  this  kind  in  ancient  literature,  reference  may  be 
made  to  one  by  Morgagni,-'  in  which  there  was,  at  the  lower  part  of  the 
breast,  an  irregularly-shaped  bossy  tumour,  of  thirty  years'  duration.  On 
one  of  these  bosses  being  incised,  an  irregular  osseous  tumour — the  size  of 
a  walnut — was  exposed. 

Numerous  instances  have  now  been  recorded  of  the  associa- 
tion of  cartilaginous  and  osseous  structures  with  malignant 
disease.  Reference  has  already  been  made  to  several  of  these  ; 
in  further  illustration  of  the  subject,  the  following  cases  will 
suffice : — 

(i)  In  one  reported  by  Battle,^- a  woman,  aged  73,  presented  with  a 
hard  circumscribed  tumour — the  size  of  a  large  orange — at  the  inner  part  of 
the  right  breast.  It  consisted  of  two  chief  bosses,  an  inner  one — the  size  of 
a  walnut — very  hard  and  rounded,  of  long  duration  ;  and  an  outer  one— much 
larger  and  more  elastic— of  comparatively  recent  formation.  The  skin  over 
the  inner  part  of  the  tumour  was  adherent  and  red,  and  the  nipple  was 
retracted.  Otherwise  it  was  freely  mobile.  There  was  a  single,  enlarged, 
hard  gland  in  the  axilla.  The  patient  said  she  first  noticed  a  hard  lump — 
the  size  of  a  pea — in  the  inner  segment  of  the  breast,  six  years  previously. 
For  the  next  two  years  there  was  no  appreciable  increase,  but  since  then  it 
had  been  progressive.  On  examination  of  the  tumour,  after  amputation  of 
the  breast,  it  was  found  to  consist  chiefly  of  soft,  vascular  substance,  which 
presented  signs  of  numerous  ecchymoses,  and  of  a  smaller  very  hard  portion 
which  resembled  bone.  Histologically  the  soft  part  consisted  of  round  and 
spindle-celled  sarcoma  tissue,  and  the  hard  part  of  ossifying  cartilage.  The 
enlarged  gland- was  lost  before  it  had  been  examined.  When  last  seen, 
about  nine  months  after  the  operation,  the  patient  was  well,  and  free  from 
return  of  the  disease. 

(2)  In  Bowlby's  case-'*  the  patient  was  a  single  woman,  aged  42,  who  had 
a  tumour  in  her  right  breast  of  one  year's  duration.  On  examination  there 
was  found,  occupying  the  outer  segment  of  the  gland,  an  ovoid  tumour  the 
size  of  an  orange.  The  overlying  skin  was  somewhat  reddened,  but  not 
adherent,  and  the  superficial  veins  were  enlarged.  The  tumour  was  freely 
mobile  ;  it  felt  hard  and  uneven  ;  there  was  marked  tenderness  on  pressure  ; 


-"  "  Illustrations  of  the  Diseases  of  the  Breast,"  p.  47. 
'-'  "  De  sedibus  et  causis  Morborum,"  &c.      Ep.  1.,  §  41. 
--  Trans.  Path.  Soc.  Loud.,  vol.  xxxvii.,  1886,  p.  473. 
-^   Trans.  Path.  Soc.  Loud.,  vol.  xxxiii.,  1882,  p.  306. 


488 


LIPOMA,    CHONDROMA,    OSTEOMA,    ETC. 


the  adjacent  lymph  glands  were  normal.  The  tumour  was  removed,  together 
with  the  whole  breast.  It  was  encapsuled,  and  in  its  general  features  re- 
sembled cystic  sarcoma  with  intra-cystic  growths.  Its  periphery  was  soft 
and  succulent  in  appearance  ;  somewhat  deeper,  a  more  fibroid  structure 
prevailed,  interspersed  with  small,  smooth,  glistening  islets  of  cartilage. 
The  central  part  of  the  tumour  presented  signs  of  mucoid  softening,  and  in 
various  parts  small  ecchymoses  were  visible.  On  cutting  into  the  tumour 
calcareous  particles  were  encountered.  Histological  examination  showed 
that  its  peripheral  part  consisted  of  small,  round  and  ovoid  cells,  embedded 


Fig.  69. — Large  osteo-chondroma  growing  from  the  ribs  in  the  mammary  region 

{Kolaczefi). 


in  homogeneous  or  fibrillar  matrix,  which  also  contained  cystic  glandular 
structure.  In  the  deeper  parts  of  the  tumour  fibrous  tissue  was  more 
abundant,  and  the  cells  were  spindle-shaped.  The  glistening  islets  em- 
bedded in  this  part  of  the  tumour  consisted  of  hyaline  or  fibro-cartilage, 
many  of  which  had  undergone  calcareous  changes  in  some  places,  and 
mucoid  changes  in  others.  The  patient  succumbed  six  months  later  with 
recurrent  disease,  but  as  there  was  no  necropsy  it  is  impossible  to  say 
whether  there  was   dissemination. 

In  this  connection  it  may  be  mentioned,  that  from  the  ribs 
and    adjacent    structures    of    this    part   of    the    thorax,   there 


ANGIOMA,    PAPILLOMA,    ETC.  489 

occasionally  arise  innocent  and  malignant  cartilage-containing 
tumours,  in  many  respects  similar  to  the  foregoing,  as  in  the 
following  cases  : — 

(i)  Kolaczek^^  reports  an  instance  of  a  large  osteo-chondroma  of  the 
mammary  region  that  originated  from  the  fourth  rib.  The  patient,  a 
woman  aged  48,  first  noticed  a  tumour  in  this  region  four  years  previously. 
On  examination,  a  very  large  tumour,  fixed  to  the  subjacent  chest  wall, 
projected  from  the  antero-lateral  part  of  the  left  side  of  the  thorax.  It 
extended  from  the  clavicle  above  to  the  costal  margin  below  (fig.  69).  In 
removing  it  large  portions  of  the  fourth,  fifth,  sixth  and  seventh  ribs,  together 
with  the  subjacent  adherent  pleura,  had  to  be  excised.  Through  the  large 
opening  thus  left  the  lung,  pericardium  and  diaphragm  could  be  plainly 
seen.  The  pleural  cavity  was  irrigated  with  salicylic  acid  solution  and 
drained.  In  a  month's  time  the  whole  wound  had  soundly  healed.  There 
remained  in  the  chest  wall  a  large  depression  (five  by  four  and  a-half  inches) 
through  which  the  heart's  movements  could  be  plainly  seen,  even  to  the 
pulsation  of  the  coronary  arteries.  On  examination,  the  tumour  was  found 
to  consist  mainly  of  hyaline  cartilage,  interspersed  with  osseous  deposits. 

(2)  Soulier^^has  reported  an  instance  of  an  osteo-chondromatous  tumour 
that  originated  in  the  mammary  region,  and  disseminated  in  the  superior 
maxilla  and  scapula. 


&     II  I. Angioma,  Papilloma,  &c. 

Angiomata  of  the  breast  are  certainly  rare.  In  the  few 
cases  that  have  been  recorded  the  disease  has  generally  affected 
the  skin  or  the  subcutaneous  tissues.  Alibert^^  mentions  having 
met  with  a  tumour  of  this  kind,  situated  over  the  pectoralis  major 
muscle,  in  the  vicinity  of  the  breast  of  a  female  child,  13  months 
old.  There  is  a  specimen  of  subcutaneous  mammary  angioma 
in  the  Hunterian  Museum,  No.  409,  of  the  pathological  series. 
It  is  thus  described  in  the  catalogue.^^ 

"  A  flattened,  lobulated,  oval  erectile  tumour  or  naevus,  removed  from 
under  the  skin  of  the  left  side  of  the  breast  of  a  child  9  months  old.  A 
small  portion  of  the  overlying  skin  is  involved  in  the  disease.  The  tumour 
consists  of  lobules  of  fibrous  tissue  and  fat,  with  numerous  large  vessels 
coursing  through  it." 


■■^*  Arch.f.  klin.  Chir.,  Bd.  xxiv. 

'^  Danphine  Med.,  Grenoble,  1^91,  xv.,  p.  261. 

■■«*  "Nosol.  Nat.,"  p.  337. 

2'  "  Path.  Catalogue,"  vol.  i. 


490  LIPOMA,    CHONDROMA,    OSTEOMA,    ETC. 

Bryant,^^  Snow,^^  Image  and  Hake.^^and  Langenbeck,^^  have 
also  recorded  instances  of  mammary  angiomata. 

In  Br3'ant's  case  the  tumour  was  the  size  of  half  a  small  orange,  and  it 
occurred  in  a  female  child  15  months  old.  It  felt  spongy,  and  was  readily 
emptied  on  pressure,  but  at  once  filled  again  when  this  was  withdrawn. 
The  whole  of  the  breast  was  involved  as  well  as  the  overlying  skin. 

In  Image  and  Hake's  case  the  disease  supervened  in  a  woman  aged  21, 
as  the  result  of  a  blow.  At  first  she  noticed  a  red  patch  on  the  skm  above 
the  nipple,  which  in  the  course  of  two  years  developed  into  a  very  large 
pulsatile  swelling.  On  examination  after  excision,  all  the  veins  in  the 
vicinity  of  the  tumour  were  dilated,  and  the  chief  of  them  presented  monili- 
form  enlargements,  the  intermediate  narrow  parts  being  markedly  thickened. 
These  veins  terminated  in  alveolar  spaces,  which  involved  the  whole  breast. 

Langenbeck's  cases  much  resembled  the  foregoing.  The  patients  were 
women  18  and  20  years  old. 

A  girl,  aged  7,  under  the  care  of  Lannelongile,^^  with  a  disc-shaped 
tumour  the  size  of  a  crown  piece,  in  the  upper  part  of  the  right  mammary 
region,  above  the  nipple,  and  apparently  not  connected  with  the  rudimentary 
mamma.  Its  periphery  lobulated.  The  tumour  freely  mobile  under  skin 
and  over  subjacent  parts  ;  although  over  its  central  part  the  skin  is  slightly 
adherent.  Here  the  skin  has  a  bluish,  purplish  colouration,  and  presents 
some  small  epidermic  plaques.  The  tumour  was  first  noticed  three  months 
previously.  On  examination,  after  extirpation,  it  appeared  to  be  composed 
of  about  half-a-dozen  communicating  small  cystic  pouches,  with  a  larger  one 
in  the  centre.  These  spaces  contained  turbid,  brownish  fluid,  with  fatty 
matters.     Evidently  it  was  a  degenerated  subcutaneous  ntevus. 

Sendler^^  has  reported  an  instance  in  which  a  cavernous  angioma  of  the 
nipple  presented  as  a  small  pendulous,  pedunculated  tumour. 

In  the  treatment  of  these  tumours,  by  excision  or  otherwise, 
care  must  be  taken  to  avoid  injuring  the  galactophorous  ducts. 

Notwithstanding  the  great  abundance  of  the  mammary 
lymphatics,  I  cannot  cite  a  single  case  of  manmiary  lymph- 
angioma; although,  as  will  be  mentioned  when  treating  of 
axillary  tumours,  there  are  on  record  several  cases  of  lymph- 
angioma in  the  vicinity  of  the  axilla. 


^  *'  Diseases  of  the  Breast,"  p.  346. 

^  Lancet,  vol.  i.,  1890,  p.  240. 

*•  Med.  Chir.  Trans.,  vol.  xxx.,  p.  109. 

"  "  Nosol.  u.  mc<l.  Therap.  dei  cliir.  Kr.nnkh.,"  Bd.  v.,  S.  83. 

■'-■  "Traite  des  Kystes  Congenitaux,"  1886,  p.  391. 

'■'•  Cent.f.  Chir.,  No.  29,  1889,  S.  52. 


ANGIOMA,     PAPILLOMA,    ETC.  49 1 

Two  cases  of  a-viyelinic  neuromata  of  the  mamma  have  been 
recorded  by  Tripier.^^ 

Papilloniata  of  the  tegumentary  system  of  the  female  breast 
are  occasionally  met  with.  My  analysis  of  2,397  mammary 
neoplasms  includes  three  instances  of  this  kind.  They  are 
oftener  found  growing  from  the  nipple  or  areola  than  elsewhere. 

There  is  a  specimen  of  a  pedunculated  papilloma  in  the  Hunterian 
Museum  (No.  4,819  A),  that  was  removed  from  the  nipple  of  a  married 
woman,  aged  38. 

Bryant^^  has  described  and  figured  a  papillomatous  growth,  the  size  of 
a  nut,  which  grew  from  the  extremity  of  the  nipple  of  a  woman  aged  48. 
It  was  of  twenty-six  years'  duration.  She  was  the  mother  of  ten  children, 
all  of  whom  she  had  suckled. 

In  this  connection  it  is  well  to  remember  that  villous  duct 
papillomata  sometimes  project  from  the  nipple. 

A  case  of  leio-myovia  of  the  right  nipple  has  been  put  on 
record  by  Sokolow.^*^  Moles  are  also  met  with  in  connection 
with  the  mammary  integument. 


^*  "  Diet.  Encycl.  des  Sci.  Med.,  '  art.  "  Mamelle." 

^'^  "  Diseases  of  the  Breast,"  p.  333. 

^^  Arch.  f.  path.  Anat.,  Bd.  Iviii.,  1873,  316. 


492 


CHAPTER  XX. 

Cystic  Disease  and  Cysts. 


The  varieties  of  cystic  disease  that  arise  in  connection  with 
neoplasms,  have  been  sufficiently  described  in  the  preceding 
chapters.  There  now  remain  for  consideration  those  rarer  forms 
that  originate  independently  of  neoplasia.  Instances  of  this  kind 
are  not  very  common.  Of  2,397  consecutive  mammary  tumours, 
analysed  by  me,  only  63  were  cysts,  or  2'6  per  cent. 

The  pathogeny  of  mammary  cysts  is  still  a  subject  of  much 
obscurity,  and  requires  to  be  thoroughly  re-investigated.  The 
cardinal  fact  hitherto  revealed  is,  that  the  great  majority  of  these 
cysts  originate  in  connection  with  Xhe  glandular  structures  of  the 
part.  Moreover,  it  appears  that  it  is  from  the  ducts,  rather  than 
the  acini,  that  they  spring,  the  small  ducts  {conduits  aciniens) 
being  more  frequently  involved  than  the  larger  ones.  The 
tumours  thus  formed  seldom  have  closed  sacs,  detachable  from 
the  surrounding  parts  ;  but  they  present  as  pouched  protrusions 
or  dilatations  of  the  pre-existing  structures.  Recent  investiga- 
tions point  to  the  probability  of  these  changes  being  due  to  the 
presence  of  some  source  of  irritation  within  the  affected  ducts, 
probably  of  microbic  origin. 

Of  the  cysts  that  arise  in  connection  with  the  larger  ducts, 
two  varieties  may  be  recognised,  according  to  the  nature  of  their 
contents — the  mucoid  and  the  lacteal. 


MUCOID    CYSTS.  493 

§     I. Mucoid  Cysts. 

These  cysts  are  so  named  because  their  contents  are  secreted 
by  the  glandular  structures  whence  they  originate  ;  hence  their 
contents  more  or  less  resemble  the  pseudo-secretions  found  in 
dilated  ducts.  When  of  some  size,  the  fluid  they  contain  is 
usually  of  a  pale  yellowish,  quasi-serous  or  opalescent  aspect ; 
the  contents  of  smaller  cysts  often  present  a  viscid,  greasy,  or 
mucoid  appearance, and  their  colour  may  be  dirty  brown,  greenish 
or  reddish.  Histologically,  epithelial  cells  in  granulo-fatty  de- 
generation, corpuscles  of  Gliige,  oil  globules  and  granulo-fatty 
debris  diVe  generally  to  be  found  in  the  fluid;  and  sometimes  cho- 
lesterine  scales  and  haematin  crystals.  No  matter  what  appear- 
ance the  fluid  presents,  it  always  contains  more  or  less  albumen. 
The  cyst  wall  is  generally  thin,  and  blended  with  the  surrounding 
parts.  Externally  it  consists  of  fibrous  tissue,  and  internally  it 
is  lined  by  a  layer  of  cubical  epithelium.  Cysts  of  this  kind  are 
usually  single,  and  they  are  of  commoner  occurrence  in  the 
vicinity  of  the  nipple  and  areola  than  elsewhere.  Not  unfre- 
quently  more  than  a  single  cyst  is  present.  Both  breasts  are 
seldom  affected.  They  generally  present  as  smooth,  rounded, 
or  ovoid  tumours — of  slow  growth — varying  in  size  from  a  wal- 
nut to  a  goose's  egg.  They  are  often  so  tense  that  fluctuation 
may  be  difficult  to  make  out.  A  valuable  diagnostic  sign  is 
that  on  pressure  fluid  may  often  be  made  to  escape  from  the 
nipple.  The  tumour  has  no  adhesions  with  the  overlying  skin, 
or  other  adjacent  parts.  The  nipple  is  not  retracted,  nor  are 
the  axillary  glands  usually  enlarged.  It  is  usually  a  painless 
affection,  and  there  is  no  tenderness  on  pressure.  The  persons 
who  most  commonly  bear  these  cysts  are  young  adult  and 
middle-aged  women ;  hardly  ever  are  they  met  with  before 
puberty.  When  unassociated  with  neoplastic  action,  these 
cysts  are  of  a  perfectly  innocent  nature.  In  cases  of  doubtful 
diagnosis,  the  tumour  should  be  aspirated.  Similar  cysts  may 
rarely  arise  in  connection  with  the  glandidcB  lactifercs  aberrantes. 
Velpeau^  mentions  the  case  of  a  young  girl  with  a  tumour  of 

'  "  Traite  des  Maladies  du  Sein,"  &c.,  p.  251. 


494  CYSTIC    DISEASE    AND    CYSTS. 

this  kind,  who  could  express  fluid  through  a  pore  near  the 
base  of  the  nipple. 

The  most  effectual  and  satisfactory  mode  of  treatment  is  that 
of  dissecting  them  out ;  or  the)'  may  be  incised  and  stuffed  with 
a  strip  of  lint  soaked  in  tincture  of  iodine.  In  some  cases  cure 
has  been  effected  simply  by  evacuation — either  by  pressing  the 
contents  out  through  the  nipple  or  by  puncture  ;  in  either  case 
combined  with  subsequent  compression. 

The  two  following  instances  have  come  under  my  notice  : — 

(i)  A  well  nourished  and  healthy  looking,  dark  complexioned,  unmarried 
woman,  aged  47,  by  occupation  a  dressmaker,  presented  herself  with  a 
rounded  tumour,  the  size  of  a  small  walnut,  immediately  beneath  the  right 
nipple.  It  was  freely  movable.  The  axillary  glands  and  the  nipple  were 
normal,  and  so  was  the  opposite  breast.  Three  weeks  previously  she  first 
noticed  a  lump  in  the  site  of  the  present  disease.  No  history  of  any  previous 
injury  or  disease  of  the  part.  Catamenia  ceased  at  42.  Her  previous  health 
had  been  indifferent,  and  she  had  generally  been  weak  and  nervous.  She 
had  rheumatic  fever  at  17,  and  typhoid  fever  at  yj.  Her  father's  sister  died 
of  cancer  of  the  breast,  three  of  her  brothers  and  sisters  had  died  of  phthisis. 
The  tumour  was  dissected  out — a  thin-walled  cyst  containing  clear,  pale 
yellowish  fluid. 

(2)  An  ill  nourished,  single  woman,  aged  67,  subsisting  by  needlework. 
At  the  centre  of  her  left  breast  is  a  globular,  fluctuating  tumour,  the  size  of  a 
Tangerine  orange.  About  its  periphery  some  ill-defined,  rather  hard  nodules 
can  be  felt,  as  of  lobular  hypertrophy.  The  overlying  skin  is  slightly 
reddened  and  adherent.  There  is  no  enlargement  of  the  axillary  glands  ; 
but  the  nipple  is  retracted,  the  latter  condition  being  of  congenital  origin. 
Tumour  of  the  breast  was  first  noticed  fourteen  months  ago,  and  she  thought 
it  due  to  a  blow.  She  had  rheumatic  fever  at  19,  and  has  since  been  subject 
to  rheumatism.  Her  mother  died  of  "  tumour  of  the  brain."  The  tumour 
was  incised,  when  clear  fluid  escaped,  and  drained.  Three  weeks  later  the 
opening  had  almost  completely  closed. 


§     II. Lacteal  Cysts  (Galactoceles). 

Galactoceles  are  cysts  containing  milk,  or  some  of  the  various 
substances  resulting  from  its  modification.  In  other  respects 
galactoceles  much  resemble  the  cysts  last  described,  and  like 
them  they  are  of  rare  occurrence.  Most  galactoceles  contain  pure 
milk,  but  fairly  often  their  contents  are  butter-like,  creamy, 
caseous  or  cheesy.      They  generally  present  as  solitary,  tense, 


LACTEAL    CYSTS.  495 

ovoid  or  rounded  tumours,  of  no  great  size,  situated  beneath 
the  nipple  or  areola.  In  exceptional  instances  cysts  of  this  kind 
may  be  very  large,  containing  many  pints  of  fluid.  In  a  case 
treated  by  Scarpa^  the  tumour  measured  thirty-two  inches  in 
circumference,  and  reached  the  patient's  thigh.  Galactoceles 
develop  painlessly  and  without  inflammatory  symptoms.  They 
contract  no  adhesions  with  the  overlying  skin,  nor  with  sub- 
jacent parts.  The  nipple  is  not  retracted,  nor  are  the  axillary 
glands  enlarged.  When  the  cysts  contain  milk,  fluctuation  may 
be  detected  ;  when  cheesy  matters,  they  pit  on  pressure.  In  the 
former  instances,  on  pressing  the  tumour,  milk  may  be  made  to 
escape  from  the  nipple,  but  this  sign  is  not  of  much  diagnostic 
importance,  except  in  the  absence  of  lactation.  Galactoceles 
almost  invariably  arise  during  lactation.  The  development  of  a 
tumour  in  the  breast,  at  or  about  the  lactation  period,  should 
always  excite  the  suspicion  of  galactocele.  It  does,  however, 
very  exceptionally  happen,  that  cysts  of  this  kind  develop  inde- 
pendently of  lactation,  as  in  Bouchacourt's"*  remarkable  case,  in 
which  a  large  milk-containing  cyst  formed  in  the  breast  of  a 
woman,  aged  51,  twenty-four  years  after  her  last  pregnancy.  In 
an  instance  reported  by  Altee''  a  similar  tumour  developed  six- 
teen months  before  childbirth.  Galactoceles  are  chronic  forma- 
tions. With  the  subsidence  of  lactation  they  generally  diminish 
in  size,  but  hardly  ever  do  they  disappear  spontaneously.  At 
each  fresh  pregnancy  there  is  apt  to  be  fresh  enlargement.  They 
may  inflame,  suppurate  or  ulcerate  ;  and  there  are  good  reasons 
for  believing  that  a  certain  proportion  of  mammary  abscesses — ■ 
both  of  the  acute  and  chronic  type — originate  in  this  way.  In 
cases  of  doubtful  diagnosis  an  exploratory  puncture  or  incision 
should  be  made.  Some  pathologists  believe  that  in  certain 
cases  the  cyst  formation  is  the  result  of  ductal  rupture  and  ex- 
travasation ;  however  this  may  be,  a  considerable  proportion  of 


-'  Cited  by  Forget,  Bull,  de  Therapeutique,  1844,  t.  xxvii.,  p.  356. 

■'  Cited  by  Richelot,  "  Des  Tiuneurs  kystiques  de  la  Mamelle,"  1878,  p.  18. 

*  Am.  /.  Med.  Set.,  April,  1874,  P-  A^9- 


496  CYSTIC    DISEASE    AND    CYSTS. 

those  who  bear  these  tumours,  attribute  them  to  the  effect  of 
injury. 

In  the  treatment  of  galactocele  the  first  thing  is  to  suspend 
suckhng  and  to  arrest  lactation,  by  the  local  application  of 
belladonna  and  glycerine,  to  which  ung.  plumbi  iodtdi  may  be 
advantageously  added  ;  and  these  measures  may  be  supple- 
mented, if  necessary,  by  the  use  of  the  breast  pump.  For  the 
cure  of  the  tumour,  incision  with  evacuation  of  its  contents, 
and  the  insertion  into  the  empty  cyst  of  a  strip  of  lint  steeped 
in  tr.  iodi.,  usually  suffices.  A  more  radical  method  is  to  dis- 
sect out  the  cyst  wall,  the  wound  being  treated  antiseptically, 
and  closed  by  deep  and  superficial  sutures,  so  as  to  ensure 
union  by  first  intention.  Puncture  with  injection  has  also  been 
resorted  to,  but  I  cannot  recommend  it.  Small  galactoceles 
have  occasionally  been  cured  simply  by  expressing  their  con- 
tents through  the  nipple  ;  and  then  applying  pressure,  and  some 
discutient  ointment. 

The  two  following  illustrative  cases  are  from  the  University 
College  Hospital  Reports.^ 

(i)  A  married  woman,  aged  42,  six  months  previously  noticed  a  small, 
painful  lump  in  her  left  breast.  No  injury  or  other  known  cause.  On  ex- 
amination a  hard,  nodular,  mobile  tumour — the  size  of  a  Barcelona  nut — 
presents  at  the  inner  part  of  the  breast.  The  nipple  normal  ;  and  no 
enlargement  of  the  axillary  glands.  It  was  excised  through  an  incision 
radiating  from  the  nipple.  The  wound  soon  healed.  Examination  of  the 
tumour  revealed  a  smooth-walled  cyst,  one-third  of  an  inch  in  diameter, 
surrounded  by  indurated  fibro-fatty  tissue,  which  contained  soft  cheesy 
substance,  evidently  inspissated  lacteal  secretion. 

(2)  A  woman,  aged  43,  three  months  after  a  miscarriage,  first  noticed  a 
hard  tumour  in  her  left  breast.  On  examination  a  very  hard,  mobile  cir- 
cumscribed swelling — the  size  of  a  walnut — was  found  there.  The  nipple 
was  not  retracted,  neither  were  the  adjacent  glands  enlarged.  It  was 
incised,  and  inspissated  milk  evacuated.  The  wound  subsequently  healed 
by  granulation  from  the  bottom. 

Illustrative  cases  have  been    recorded    by  Bryant,^    Klotz,^ 


•'■  Q.v.    Report  for  1888,  p.  761,  and  for  1884,  p.  51. 
*  "  Diseases  of  the  Breast,"  1887,  p.  311,  et  seq. 
'  Arch.  f.  klin.  Chir.,  1880,  Bd.  xxv.,  S.  47. 


GENERAL    CYSTIC    DISEASE.  497 

Gould,«  Gillette,^  Jobert,^"  Piiech,''  Birkett/^  Velpeau/'^  Forget,^* 
Astley  Cooper,^''  and  others.  I  have  elsewhere^^  related  some 
remarkable  instances  of  axillary  galactoceles. 


§     II  I. General  Cystic  Disease. 

Among  the  moderns,  Astley  Cooper  was  the  first  who  clearly 
recognised  the  occurrence  in  the  breast  of  a  general  cystic 
disease,  chiefly  affecting  the  small  ducts  ;  and,  following  his 
lead,  Brodie  was  the  first  who  published  a  comprehensive  de- 
scription of  this  malady.  Strange  to  relate,  notwithstanding 
their  completeness,  the  observations  of  these  distinguished 
surgeons  gradually  lapsed  into  oblivion  ;  so  that  when  in  1883 
Reclus^''  published  a  fresh  account  of  the  disease,  almost  every 
one,  even  in  England,  hailed  his  observations  as  a  new  discovery, 
and  the  disease  has  since  been  generally  known  as  "/«  Maladie 
kystiqiie  de  Reclus." 

Nevertheless,  almost  every  particular  noted  by  Reclus,  and 
some  that  escaped  his  observation,  had  previously  been  described 
by  Brodie  ;  if,  therefore,  the  personal  element  is  to  be  intro- 
duced into  the  nomenclature  of  this  affection,  "  Brodie's  disease" 
would  be  a  much  more  appropriate  term  for  it  than  "  Reclus' 
disease."  His  neglected  account  of  the  malady,  as  far  as  it 
goes,  is  still  the  best  extant,  so  I  propose  to  give  it  in  extenso. 
He  says  :  ^^ — 


*  Lancet,  vol.  ii.,  1880,  p.  850. 

"  nUnion  Med.,  t.  xxv.,  1878,  pp.  945,  957  and  993^ 
'"  Gaz.  des  Hop.,  1863,  p.  525. 
"  Monit.  des  Sci.  Med.,  Ssrc,  i860,  p.  4. 

'-  "  Holmes'  System  of  Surgery,"  vol.  iii.,  1883,  p.  448  ;  also  "  Diseases  of  the 
Breast,"  1850,  p.  201. 

'^  "Traite  des  Maladies  du  Sein,"  &c.,  1854.  p.  297. 

'^  Bull  gin.  de  Therapeutiqiie,  1844,  t.  xxvii. ,  p.  355. 

''^  "  Illustrations  of  the  Diseases  of  the  Breast,"  1829. 

"■  Ch.  iv.,  §  iv. 

"■  Riv.  de  Chir.,  1883,  p.  761. 

'"  "Lectures  on  Pathology  and  Surgery,"  1846,  p.  137. 


49^  CYSTIC    DISEASE    AND    CYSTS. 

"The  disease  of  which  I  propose  to  treat  on  the  present  occasion,  is  an 
affection  of  the  female  breast.  It  is  one  of  great  interest  in  various  ways, 
and  among  others  in  this  :  that  in  its  more  advanced  stages,  ahhough  it  is 
not  really  of  a  malignant  nature,  it  is  liable  to  be  confounded  with  carcinoma. 
I  have  not  met  with  any  description  of  it  in  books  corresponding  to  what 
I  have  myself  observed  of  its  actual  progress.  You  will  presently  see  that 
this  is  easily  to  be  explained  by  the  disease  assuming  a  wholly  new 
character  as  it  proceeds,  so  that  if  you  were  to  look  at  two  cases  of  it,  one 
in  an  early,  and  the  other  in  a  more  advanced  stage,  without  having 
witnessed  the  intermediate  changes  which  have  taken  place,  you  would  be 
scarcely  able  to  recognise  their  identity.  Let  me  not,  however,  be  mis- 
understood as  representing  that  no  notice  whatever  has  been  taken  of  this 
disease  by  surgical  writers.  The  account  which  Sir  Astley  Cooper  has 
given  of  the  hydatid  breast  has  been  taken  principally  from  cases  of  this 
kind,  and  there  are  also  some  allusions  to  it  in  the  '  Treatise  on  Diseases 
of  the  Breast,'  lately  published  by  M.  Velpeau. 

"  The  first  perceptible  indication  of  the  disease  is  a  globular  tumour 
embedded  in  the  glandular  structure  of  the  breast,  and  to  a  certain  extent 
movable  underneath  the  skin.  Sometimes  there  is  only  one  such  tumour  ; 
at  other  times  there  are  two  or  three,  or  many  more.  The  examination  of 
the  breast  in  the  living  person  does  not  enable  you  to  determine  the  exact 
number  which  exist,  as  it  is  only  where  they  have  attained  a  certain 
magnitude  that  they  are  perceptible  through  the  skin.  In  most  instances 
the  disease  is  confined  to  one  breast,  though  it  is  by  no  means  very  un- 
common for  both  breasts  to  be  similarly  affected. 

"The  globular  form  which  the  tumour  invariably  assumes  in  the  first 
instance,  is  a  sufficient  proof  that  it  is  formed  of  fluid  collected  in  a  cyst, 
and  of  course  pressing  equally  in  every  direction.  If  you  puncture  the 
tumour  with  a  grooved  needle,  the  fluid  may  be  evacuated  so  as  completely 
to  empty  the  cyst,  and  the  perfect  subsidence  of  it  afterwards  proves  how 
little  space  the  cyst  itself  occupies.  The  fluid  is  always  serous.  When  the 
tumour  is  small  it  seems  to  be  serum,  unmixed  with  anything  else.  In  a 
more  advanced  stage  of  the  disease,  some  colouring  matter  is  generally 
blended  with  it,  and  it  may  be  green,  or  brown,  or  so  dark-coloured  as  to 
be  almost  black.  The  quantity  of  fluid  of  course  varies.  In  dissection, 
I  have  sometimes  found  the  cyst  to  be  so  small  as  to  contain  scarcely  a 
single  drop.  But  in  a  more  advanced  stage  it  is  capable  of  containing 
several  ounces.  In  two  cases,  in  each  of  which  I  had  the  opportunity  of 
dissecting  a  breast  affected  with  this  disease,  I  found  small  cysts,  composed 
of  a  thin  membrane,  and  containing  serum,  pervading  the  whole  of  the 
glandular  structure,  the  intermediate  parts  of  the  breast  presenting  a 
perfectly  healthy  and  natural  appearance  ;  and  I  could  discover  nothing 
more.  There  seems  to  be  little  doubt  that  the  cysts  are  originally  formed 
by  a  dilatation  of  the  lactiferous  tubes.  In  one  of  the  preparations  now 
on  the  table,  you  will  perceive  a  bristle  introduced  into  the  orifice  of 
one  of  these  tubes  opening  on  the  nipple,  which  has  passed  into  a  cyst 
immediately  below  ;  and  it  is  not  uncommon  to  find  that  by  pressure  on  the 
tumour  the  fluid  may  be  made  to  escape  by  the  nipple,  so  that  you  may 
even  expel  the  whole  of  it. 


GENERAL    CYSTIC    DISEASE. 


499 


"  To  complete  the  history  of  the  disease,  as  it  first  shows  itself,  I  may  add 
that  the  general  health  is  unaffected,  and  that  the  patient  complains  of  no 
pain,  unless  it  be  that,  in  some  instances,  there  are  those  disagreeable 
nervous  sensations  that  are  apt  to  arise  whenever  the  attention  is  anxiously 
directed  to  any  one  part  of  the  body.  I  have  never  known  the  disease  to 
occur  previously  to  the  age  of  puberty  ;  it  is  rare  after  the  middle  period  of 
life,  and  I  am  inclined  to  believe  it  is  more  common  in  single  than  in 
married  women." 

It  is  clear  from  the  above  that  Brodie  was  perfectly  familiar 
with  every  phase  of  this  disease,  and  the  following  quotation 
proves  that  he  knew  also  how  to  discriminate  it  from  cystic 
tubiilar  cancer — a  disease  that,  in  its  clinical  features,  is  very  like 
it.     On  this  subject  he  thus  expresses  himselP^ : — 


Fig.  70. — Multiple  cystic  disease  {Gross). 

"  There  are  not  a  few  cases  in  which  no  morbid  changes  take  place 
beyond  those  that  I  have  already  described  ;  the  cyst  remaining  unaltered, 
or  only  slowly  increasing  in  size  during  the  remainder  of  the  patient's  life. 
But  in  other  cases  the  tumours  lose  their  globular  form,  and  a  solid  substa7ice 
is  deposited  ifi  the  breast,  connecting  different  cysts  with  each  other  i?i  one 
large  mass  of  disease.  This  process  may  be  going  on  for  many  successive 
years  without  inducing  pain  or  much  inconvenience,  except  what  belongs  to 
the  bulk  of  the  tumour.  But  the  period  at  last  arrives  when  other  changes 
take  place,  the  disease  assuming  a  more  formidable  and  dangerous  character. 
The  skin,  being  in  some  one  part  more  tense  and  thin  than  elsewhere, 
becomes  inflamed  and  ulcerates,  and  an  intractable  and  bleeding  ulcer  is 
the  consequence,  &c." 


'"  Op.  cit.,  p.  140. 


500  CYSTIC    DISEASE    AND    CYSTS. 

Elsewhere  he  also  recognises  the  existence  of  a  form  of 
non-malignant  cystic  disease  associated  with  intra-cystic  villous 
growths. 

In  his  description  of  the  malady  Reclus^°  lays  stress  on 
the  frequency  with  which  both  breasts  are  affected,  each  gland 
being  riddled  throughout  with  small  cysts,  so  that  hundreds 
may  be  visible  to  the  naked  eye,  of  which  denser  aggrega- 
tions are  met  with  at  the  periphery  and  posterior  surface  of 
the  gland  than  elsewhere.  In  these  cases  it  usually  happens 
that  one  or  more  cysts  in  the  vicinity  of  the  nipple  increase  in 
excess  of  the  others  so  as  to  form  an  obvious  tumour,  varying  in 
size  from  a  cherry  to  a  walnut.  It  is  the  discovery  of  such  a 
tumour  that  usually  constitutes  the  patient's  first  intimation  of 
there  being  anything  wrong  with  the  breast.  On  examination  the 
surgeon  finds  in  this  situation  one  or  more  smooth,  rounded  or 
ovoid  tumours,  feeling  it  may  be  very  hard,  so  that  fluctuation 
is  not  readily  elicited,  while  on  careful  palpation  of  the  rest  of 
the  gland  numerous  small,  hard,  shot-like  nodules  may  be  felt 
disseminated  through  it.  On  examination  of  the  opposite 
breast  the  larger  central  tumours  are  usually  absent,  but  the 
small,  shot-like  bodies  can  generally  be  felt.  The  other 
symptoms  are  of  the  negative  kind.  The  nipple  and  skin  are 
normal,  there  arc  no  adhesions  between  the  breast  and  adjacent 
parts ;  and  the  axillary  glands  are  not  affected  except  when 
irritative  conditions  co-exist.  The  great  hardness  sometimes 
manifested  by  these  tumours  has  occasionally  caused  them  to  be 
mistaken  for  hard  cancer,  from  which  they  may  be  readily  dis- 
tinguished by  exploratory  puncture.  Most  cases  are  met  with 
between  the  ages  of  30  and  40  years. 

Since  Reclus'  publication  numerous  droc/iures— mostly  by 
French  writers — have  appeared,  dealing  with  the  morphological 
aspects  of  this  disease.  Nearly  all  agree  in  describing  the  cysts 
as  lined  by  epithelium  of  the  columnar  type  ;  when  more  than  a 
single  layer  of  lining  cells  is  present  the  columnar  type  is  well 


0/>.  cit. 


GENERAL    CYSTIC    DISEASE.  5OI 

marked  in  the  peripheral  cells,  although  it  may  be  lost  in  the 
more  central  ones.  This  was  the  condition  present  in  all  the 
specimens  that  I  have  myself  examined.  It  clearly  points  to 
the  origin  of  the  cysts  from  the  small  ducts,  yet  nearly  all  the 
authors  referred  to  state  that  they  are  of  acinous  origin.  I  have 
never  seen  any  structure  having  the  least  resemblance  to  an 
acinus,  in  specimens  of  general  cystic  disease  of  the  breast. 
The  cysts  arise  as  solid  cellular  buds  from  the  small  ducts. 
Lately  histologists  have  concentrated  their  attention  on  the 
stromal  tissues  in  the  immediate  vicinity  of  the  small  cysts.  In 
a  considerable  proportion  of  the  specimens  examined,  signs  of 
chronic  inflammatory  lesions  have  been  met  with  here ;  this  has 
induced  Delbet^^  and  others  to  maintain,  that  cystic  disease  of 
the  breast  is  always  a  deuteropathic  phenomenon.  I  have,  how- 
ever, in  some  specimens  been  unable  to  discover  any  trace  of 
past  or  present  inflammatory  action.  This  is  especially  the 
case  with  that  form  of  the  disease,  which  arises  in  association 
with  atrophic  changes  of  the  glandular  structures,  such  as 
normally  ensue  during  the  involution  period. 

The  diagnosis  of  general  cystic  disease  from  cystic  tubular 
cancer,  and  multiple  papilloma  of  the  diffuse  kind,  is  often 
very  difficult.  An  important  point  of  difference  is  that 
in  the  two  latter  affections  the  disease  involves  only  one 
breast ;  moreover,  the  papillomata  frequently  cause  sanious 
discharge  from  the  nipple,  and  the  tubular  cancers  occasionally 
disseminate  in  the  axillary  glands.  Except  when  large  cysts 
form  in  the  vicinity  of  the  nipple,  general  cystic  disease  rarely 
presents  as  a  distinct  tumour  \  whereas  in  the  other  two  affections 
well-marked  tumours  usually  form.  The  differential  diagnosis 
from  chronic  mastitis  will  be  considered  when  treating  of  the 
latter  subject. 

When  this  disease  causes  no  great  deformity,  and  is  not 
otherwise  intolerable  to  the  patient,  it  is  not  necessary  to  resort 


-'  '*  Maladie  Kystique  et  Mamtnite  Chronique,"  Bull,  de  la  Soc.  Anat.,  2  Jan., 
18Q-V 


502  CYSTIC    DISEASE    AND    CYSTS. 

to  heroic  treatment.  In  the  absence  of  large  cysts,  it  will  suffice 
to  apply  to  the  breast  an  application  consisting  of  equal 
parts  of  belladonna  in  glycerine,  with  iodide  of  lead  ointment ; 
together  with  moderate  compression  by  bandaging,  strapping  or 
by  special  apparatus.  When  one  or  more  large  cysts  exist  these 
may  be  incised,  evacuated  and  plugged  with  a  pledget  of  lint, 
steeped  in  tincture  of  iodine.  When  such  treatment  does  not 
suffice,  the  breast  should  be  removed  by  Thomas'  operation,  the 
overlying  skin,  nipple  and  areola  being  carefully  preserved,  so  as 
to  minimise  the  subsequent  deformity.  In  doing  this  care  must 
be  taken  completely  to  remove  the  glandular  elements,  for  if 
these  are  left  behind  they  may  become  the  germs  of  fresh  cystic 
disease,  as  in  a  case  of  much  interest  reported  by  R.  Johnson ,^^ 
of  which  the  following  is  an  abstract. 

Miss ,  aged  33,  came  under  treatment  with  general  cystic  disease  of 

the  left  breast,  for  which  it  was  extirpated.  Several  of  the  larger  cysts 
contained  villous  ingrowths.  Four  years  later  the  right  breast  was  ex- 
tirpated for  similar  disease.  Twelve  years  after  the  first  operation,  the  patient 
again  came  under  observation  with  a  mobile  rounded  tumour  just  above  the 
middle  of  the  scar,  resulting  from  extirpation  of  the  left  breast.  It  had  been 
slowly  growing  for  two  years.  On  examination  after  removal  it  was  found 
to  consist  of  two  cysts  of  some  size,  containing  villous  ingrowths,  surrounded 
by  numerous  minute  cystic  glandular  formations.  In  this  case  recurrence 
was  probably  due  to  some  of  the  peripheral  mammary  processes  having 
been  left  behind  at  the  first  operation. 

For  further  information  as  to  this  disease  reference  may  be 
made  to  publications  by  Bcsancon  and  Broca,^^  Brissaud,-^ 
Moullin,-'^  Sicre,-'^  Pilliet,-'  Verchere,^''  Sourice.^"  Schimmel- 
busch,^'^  &c. 


"    Trans.  Path.  Soc.  I.oiid.,  1892. 

=»  Le  Prog.  Mc'd.,  mars,  1SS6. 

-'  Arch,  de  Phys.,  1884,  p.  98. 

*■  Journal  of  Anatomy.,  vu\.  xv.,  p.  346. 

'^   Thise  de  Paris,  No.  77,  1890. 

-"  Bui/,  de  la  Soc.  Anat.,  9  Jan.,  1891. 

-*  //dd.,  4  juillet,  1890. 

■-'   Thhe  de  Parts,  1887. 

="  Arch.  f.  path.  Anat.,  Bel.  xiiv.,  S.  1 17. 


LYMPHATIC    CVSTS.  5O3 

O     IV. Lymphatic    Cysts. 

It  has  been  demonstrated  by  Labbe  and  Coyne,^'  that  the 
stroma  of  the  mamma,  and  the  connective  tissue  in  its  vicinity, 
contain  numerous  large  lymphatic  lacunae,  which  are  lined  by  a 
single  layer  of  flattened  endothelial  cells,  exhibiting  the  char- 
acteristic reaction  when  stained  with  nitrate  of  silver.  In  the 
breast  cysts  are  occasionally  met  with  lined  by  similar  cells. 
Such  cysts  no  doubt  arise  from  the  distension  of  these  lym- 
phatic lacunae,  owing  to  the  undue  accumulation  of  fluid  within 
them.  They  may  be  either  single  or  multiple.  They  differ  from 
the  foregoing  in  that  each  forms  a  perfectly  closed  sac,  having  no 
communication  with  the  glandular  structures.  Villous  intra- 
cystic  growths  have  not  been  found  in  these  cases.  They 
usually  contain  a  clear,  pale  yellowish  or  brown,  mucoid  fluid. 
In  size  they  seldom  exceed  a  pigeon's  egg.  Being  deeply  seated 
and  surrounded  by  unyielding  structures,  these  cysts  often  feel 
very  tense  and  hard  ;  and  as  fluctuation  can  seldom  be  detected, 
they  have  often  been  mistaken  for  hard  cancer.  However,  unless 
associated  with  inflammatory  changes,  as  not  unfrequently 
happens,  they  never  cause  dimpling  of  the  overlying  skin,  retrac- 
tion of  the  nipple,  nor  enlargement  of  the  axillary  glands.  Most 
exam^ples  have  been  met  with  in  patients  over  40  years  of  age. 
In  the  cases  hitherto  recorded  the  affection  has  invariably  been 
unilateral.  The  so-called  bursa  of  Chassaignac,  occasionally 
found  between  the  breast  and  the  sheath  of  the  pectoralis  major 
muscle,  is  likewise  generally  regarded  as  originating  from  cystic 
lymphatic  lacunae.  The  same  means  of  treatment  are  suitable 
for  these  cases  as  for  the  previously  described  varieties  of  mam- 
mary cysts  ;  they  may  be  incised  and  evacuated,  &c.,  or  dissected 
out.     The  following  illustrative  case  is  by  Pollard.^- 

The  patient,  aged  44,  two  months  previously  accidentally  noticed  a 
lump  in  her  breast.  There  was  no  known  cause  for  it.  On  examination  a 
tumour  the  size  of  a  marble  was  found  in  the  midst  of  an  indurated  lobule. 


''   "  Traite  des  Tumeurs  Benignes  du  Sein,"'  p.  90. 
'■'-  Uiiiv.   Coll.  Hasp.  Rep.,  1885,  pp.  76  and  148. 


504  CYSTIC    DISEASE    AND    CYSTS. 

The  axillary  glands  were  normal.  It  was  dissected  out  together  with  some 
of  the  adjacent  indurated  tissues  ;  and  the  wound  soon  afterwards  healed  up. 
On  examination  it  proved  to  be  a  tense  cyst,  containing  clear,  straw-coloured 
fluid.  The  cyst  wall  was  shown  by  staining  with  nitrate  of  silver  to  be  lined 
with  a  single  layer  of  flat  epithelioid  cells,  some  of  which  had  wavy  margins. 

Cases    histologically    verified    have   also    been    recorded    by 

Butlin,^^  Gadsby,^*  and  others. 

S     V. Hydatid    Cysts. 

Although  a  considerable  number  of  well  recorded  examples 
of  mammary  hydatids  have  been  published,  yet  it  is  a  very  rare 
disease.  The  taenia  embryo  finds  its  way  to  the  breast  and 
develops  there  into  the  hydatid  cyst,  just  as  it  does  in  other 
organs.  The  mother  vesicle,  surrounded  by  the  condensed 
fibrous  tissue  of  the  part,  increases  slowly — several  months 
passing  before  it  attains  the  size  of  a  nut.  In  most  cases  the 
disease  then  presents  as  a  single  cyst,  containing  clear,  non- 
albuminous  fluid  of  low  specific  gravity,  in  which,  on  histological 
examination,  the  pathognomonic  hooklets  may  be  found  ;  while, 
adhering  to  its  germinal  membrane  or  floating  in  its  contained 
fluid,  are  numerous  scolices.  At  a  later  stage  several  daughter 
cysts  may  be  present  within  the  parent  cyst.  In  the  breast  hydatid 
cysts  seldom  attain  the  immense  size  they  do  in  other  parts  ; 
however,  Astley  Cooper^^  and  Warren^*^  have  met  with  specimens 
that  weighed  from  twelve  to  fourteen  pounds,  and  contained  an 
immense  number  of  daughter  cysts.  Mammary  hydatids  usually 
present  as  smooth,  rounded,  mobile,  painless,  chronic  tumours 
about  the  size  of  a  small  apple,  which  either  fluctuate  or  are  of 
elastic  consistency.  They  occasionally  become  inflamed  and 
suppurate,  and  then  they  may  give  rise  to  adhesions  with  ad- 
jacent structures  and  enlargement  of  the  axillary  glands. 
According  to  Haussmann"^  hydatids  may  develop  in  any  part  of 


■"  Lancet,  vol.  i..  1884,  p.  748. 

^*  Laiuci,  vol  i.,  1878,  p.  234. 

'•^  "Lectures  on  Surgery,"  1839,  p.  371. 

•""  "  Surgical  Observations  on  Tumours,"  p.  206. 

■1'   "  Die  Parasilcn  der  Brustdriise,"  Berlin,  1874. 


HYDATID    CYSTS,  505 

the  breast,  except  the  nipple  and  its  imnriediate  vicinity.  They 
are  invariably  unilateral.  The  great  majority  arise  between  the 
ages  of  20  and  50.  Similar  cysts,  arising  from  structures  in  the 
vicinity  of  the  breast,  may  also  present  in  the  mammary  region. 
In  a  case  reported  by  Gardener*^^  the  tumour  sprang  from  the 
pectoralis  major  muscle  ;  in  Graefe's'^''  case  it  was  situated  beneath 
this  muscle ;  while  Schneep^^  and  Landau^^  have  met  with  in- 
stances in  which  cysts  thus  presenting  were  of  intra-thoracic 
origin.  In  cases  of  doubtful  diagnosis  exploratory  puncture 
should  be  resorted  to.  The  treatment  consists  in  incision  and 
evacuation  of  the  laminated  cyst-wall,  the  empty  cavity  being 
dressed  from  the  bottom  with  lint  steeped  in  tincture  of  iodine. 
Partial  amputation  of  the  breast,  together  with  the  cyst,  may 
in  certain  cases  be  necessary,  when  the  latter  is  of  large  size- — 
the  wound  being  closed  by  deep  and  superficial  sutures,  so  as  to 
secure  immediate  union. 

The  following  recently  recorded  examples  illustrate  the  chief 
features  of  the  disease  : — 

(i)  A  patient  of  Dubrueil's,^^  aged  44,  had  suffered  for  two  years  from  an 
indolent  tumour  of  the  breast,  which,  two  months  before  she  came  under  his 
observation,  became  painful  and  increased  rapidly.  On  making  an  ex- 
ploratory incision  into  it  purulent  fluid,  with  hydatid  membrane,  escaped. 
The  resulting  cavity  was  irrigated  with  boric  acid  lotion,  and  then  with 
nitrate  of  silver  solution.     Two  months  later  it  had  completely  healed. 

(2)^*  A  multipara,  aged  30,  two  years  ago  first  noticed  a  tumour  in  her 
right  breast.  On  examination  a  rounded,  fluctuating,  circumscribed  tumour, 
three  inches  in  diameter,  was  found  in  the  upper  part  of  the  breast.  It  was 
freely  movable,  but  the  skin  over  it  near  the  nipple  was  inflamed.  When 
punctured,  pale,  watery  fluid  escaped,  which  soon  became  slightly  opalescent, 
but  contained  no  booklets.  Through  a  vertical  incision  the  whole  tumour 
was  dissected  out.  A  little  pus  was  found  in  the  tissue  over  it  near  the 
nipple.  On  examination  after  removal,  the  tumour  was  found  to  consist  of 
a  thick  capsule  of  chronically  inflamed,  sclerosed  connective  tissue,  within 
which  was  the  hydatid  membrane.     There  were  no  secondary  cysts. 


^^  Lancet,  vol..  i,  1878,  p.  851. 

^  Arch.  Gen.  de  Med.,  t.  xvi.,  p.  593. 

^°  Cent./.  Chir.,  1876. 

«  Arch.  /.  Gyn.,  Bd.  viii.,  S.  350. 

^■^  Rev.  de  Chir.,  May,  1890. 

^^  Symonds,  Trans.  Path.  Soc.  Loud.,  vol.  xxxviii.,  18S7,  p.  448. 


506  CYSTIC    DISEASE    AND    CYSTS. 

Cases  have  also  been  reported  by  Bryant/*  Guermonprez  *® 
Fischer,*^  Henry,*''  Birkett  *^  and  others. 

Various  inert  foreign  bodies  embedded  in  the  breast,  such 
as  pins,  needles,  bits  of  glass,  altered  blood,  inspissated  tubercle, 
and  small  sequestra  from  the  ribs,  that  have  separated  by  quiet 
necrosis,  &c.,  are  occasionally  found  inside  pseudo-cystic  spaces. 

Q     V  I. Sebaceous  Cysts. 

These  are  great  rarities,  arising  chiefly  in  connection  v^ith 
the  areola,  but  exceptionally  also  from  other  parts  of  the  mam- 
mary integument. 

Billroth  ^''  mentions  the  case  of  a  very  obese  married  woman,  aged  46, 
the  mother  of  several  children,  who  died  in  hospital  after  laparo-hysterectomy 
for  uterine  myo-fibroma.  Before  operation  it  was  noticed  that  she  had  in 
her  right  breast  a  circumscribed,  .mobile,  painless  tumour,  the  size  of  a 
duck's  egg,  of  many  years'  duration  ;  and  stationary  of  late.  On  examina- 
tion of  the  part  after  death,  an  encapsuled  tumour  was  found  immediately 
beneath  the  integument,  which  on  section  contained  a  large  quantity  of 
imbricated,  cholesteatomatous  scales,  and  within  this  some  pulpy  magma. 
Billroth  thought  it  probably  originated  from  a  deep  cutaneous  sebaceous 
gland. 

He  also  mentions  having  seen  another  case,  in  which  a  sebaceous  cyst, 
the  size  of  a  pigeon's  egg,  existed  in  the  left  breast,  whose  contents  could  be 
expelled  by  squeezing  them  through  a  fine  opening  in  the  overlying  skin. 

Cruveilhier'""  has  reported  two  similar  cases  ;  both  in  the  persons  of  adult 
females  ;  in  connection  with  each  of  which  the  orifice  of  the  diseased  seba- 
ceous gland  was  plainly  visible. 

Lebert^'  also  refers  to  a  case  of  this  kind  ;  and  Bryant"'  instances  several 
examples  arising  from  the  sebaceous  glands  of  the  areola,  one  of  which  was 
pedunculated  ;  while  another,  having  ulcerated,  subsequently  became  the 
seat  of  cancer. 

Cysts  of  this  kind  should  be  dissected  out  en  masse;  in  default 
of  this  they  may  be  incised,  evacuated  and  dressed  from  the 
bottom. 


■"  "Diseases  of  the  Breast,"  1887,  p.  317. 

'*  Anil,  de  Tocologie,  188^,  p.  14. 

*"  Deutsche  Zeitschr.  f.  Chir.,  Bd.  xiv.,  S.  366. 

'^  Lancet,  vol.  ii  ,  1861,  p.  497. 

'"  "  Holmes'  System  of  Surgery,"  vol.  iii.,  1883,  p.  450. 

'"  Deutsche  Chir.,  Lief  xli.,  S.  90. 

*"  Traite  d'Anat.  Path.,  t.  iii.,  p.  338. 

*'  Bull,  de  la  Hoc.  Anat.,  1852,  p.  42. 

•'■-  "  Diseases  of  the  Breast,"  18S7,  p.  332. 


DKRMOID    CYSTS.  507 

In  this  connection  mention  may  be  made  of  the  occasional 
occurrence  on  the  breast  of  vwUuscudi  contagiosiini.  The  com- 
monest seat  for  its  development  is  the  child's  face,  and  thence 
it  may  be  communicated  to  the  mother's  breast.  It  presents 
as  sessile,  pearly-looking  rounded  tumours,  umbilicated  at  the 
centre,  and  varying  in  size  from  a  pin's  head  to  a  pea.  These 
arise  in  the  sebaceous  glands,  and  their  contents  are  sebaceous 
cells  and  their  products.  They  should  be  treated  by  incision, 
their  contents  being  squeezed  or  scraped  out. 

§   VII. Dermoid  Cysts. 

There  are  on  record  several  examples  of  dermoid  cysts 
situated  in  the  median  line,  in  the  region  of  the  sternum, 
especially  at  about  the  level  of  the  junction  of  its  first  and 
second  segments.^^  Of  these  Clutton's^^  case  is  one  of  the  most 
instructive. 

A  married  woman,  aged  38,  came  under  observation  with  a  large  pen- 
dulous tumour,  hanging  from  the  centre  of  the  sternum,  between  her  two 
breasts.  Its  circumference  measured  thirteen  inches.  It  felt  soft  and 
fluctuating.  The  overlying  skin  was  freely  mobile,  but  its  central  part 
showed  atrophic  changes,  such  as  are  not  unfrequently  seen  in  the  skin  over 
dermoid  cysts.  When  only  six  weeks  old,  a  median  pea-sized  body  is 
said  to  have  been  noticed  in  the  site  of  the  present  tumour.  At  19  years  of 
age  this  had  increased  to  the  size  of  a  hen's  ^g%.  The  cyst  was  dissected 
out.  It  had  no  connection  with  the  sternum,  which  was  normal.  Its  thin 
wall  was  lined  internally  with  epidermic  flakes,  within  which  were  eleven 
ounces  of  thick  fluid,  containing  epidermic  scales,  fatty  matter,  cholesterine, 
&c.,  but  no  hairs.  Histological  examination  of  the  cyst  wall  revealed  the 
ordinary  structure  of  cutis  vera,  but  the  papillae  were  small  and  scanty, 
and  neither  glandular  structures  nor  hair  follicles  were  visible. 

Cases  have  also  been  published  by  Bramann/^  Cahen,^^ 
Lannelongue,'"  Fontaine,  Landrieux  and  others. 

Lannelongue's  patient  was  16  years  old  when  the  cyst  was  removed. 
It  was  situated  in  the  middle  line,  in  front  of  the  upper  part  of  the  sternum. 
It  contained  numerous  hairs. 


''^  In  this  situation  there  may  occasionally  be  seen  a  median  congenital  depression 
— the  sternal  dimple. 

^*  Trans.  Path.   Soc.   Loud.,  vol.  xxxviii. ,  1887,  p.  393. 

•"  Arch.f.  klin.  Chir.,  Bd.  xl. 

'^  Zeitschr.  f.  Chir.,  Bd.  xxxi.,  S.  370. 

^'  "  Traite  des  Kystcs  Congenilaux,"'  1886.  p.  27,  also  p.  195. 


508  CYSTIC    DISEASE    AND    CYSTS. 

Dermoids  of  the  breast  itself  are  of  much  rarer  occurrence 
than  the  foregoing  ;  the  following  are  some  of  the  chief  examples 
hitherto  recorded  : — 

(i)  In  the  lower  half  of  the  right  breast  of  a  woman,  aged  66,  who  died  of 
emphysema  of  the  lungs,  Hermann"'^  found  a  globular  tumour  bigger  than  a 
man's  fist.  The  skin  over  its  most  projecting  part  was  ulcerated,  and  on 
squeezing  the  tumour  caseous  matter,  together  with  large  epidermic  flakes, 
escaped  through  the  ulcer.  No  satisfactory  history  of  the  disease  could  be 
obtained.  Hermann  suggests  that  the  cyst  originated  as  a  sequestration 
from  the  epiblastic  ingrowth  of  the  developing  gland. 

(2)  Reverdin  and  Mayor^*  relate  the  case  of  a  woman,  aged  47,  with  a 
tumour  of  the  left  breast,  the  size  of  a  child's  head.  The  overlying  skin 
mobile,  purplish  and  marked  by  enlarged  veins  ;  the  nipple  normal.  The 
main  tumour  seemed  distinctly  to  fluctuate,  but  adjacent  to  it  several  hard 
nodules  could  be  felt.  The  history  the  patient  gave  was,  that  twenty-eight 
years  ago,  after  having  suckled  for  fifteen  months  her  first  child,  she  noticed 
several  hard  nodules  in  her  left  breast.  During  the  last  two  years  most  of 
the  present  large  tumour  has  developed.  After  ablation  the  main  tumour 
was  found  to  be  a  dermoid  cyst,  and  the  surrounding  hard  nodules  were 
fibro-adenomata. 

(3)  In  a  case  by  Albers,''"  the  cyst  contained  hairs  in  the  midst  of  a  quasi- 
sebaceous  magma. 

(4)  In  the  lower  and  outer  part  of  the  left  breast  of  a  healthy  multipara, 
aged  42,  Velpeau"'  found  a  circumscribed,  mobile  tumour,  the  size  of  a  fowl's 
egg.  It  was  soft,  fluctuating  and  tender.  The  axillary  glands  and  nipple 
were  normal.  When  punctured,  quasi-serous  fluid  containing  grumous 
flakes  escaped.  Fifteen  years  ago,  a  small  lump  was  first  noticed  in  the  site 
of  the  present  tumour;  it  remained  almost  stationary  until  about  eighteen 
months  ago,  since  when  it  has  rapidly  increased,  and  this  increase  has  been 
attended  with  pain  and  tenderness.  Velpeau  dissected  the  tumour  out. 
During  the  operation  it  proved  to  be  completely  embedded  in  the  tissues  of 
the  part  ;  a  thick  layer  of  fat  separating  it  from  the  overlying  skin.  On 
examination  after  removal,  it  consisted  of  a  fibrous  capsule,  blended  with 
the  surrounding  parts,  within  which  were  whitish  imbricated  epidermic 
lamellae,  forming  a  kind  of  second  cyst  wall,  which  contained  whitish-yellow 
pulp,  consisting  of  degenerating  epithelial  cells,  fatty  globules,  cholesterine 
crystals,  &c.  The  complete  way  in  which  this  tumour  was  embedded  in  the 
breast  and  the  absence  of  any  external  orifice,  are,  I  think,  sufficient  reasons 
for  regarding  it  as  a  dermoid,  rather  than  as  a  sebaceous  cyst. 

(5)  Erichsen"-  says  :  "  In  some  rare  cases,  tumours  containing  foetal 
remains  have  been  met  with  in  the  breast."  However,  he  gives  no  instances, 
and  I  know  of  none. 

•''*  Frailer  nied.   Woc/t.,  No.  44.  1890. 

■'"  Rev.    MM.  de  la  Suisse  roiiiat/de,  1887,  p.  96. 

''"  Erldiiieruni^en,   Bd.  iii.,  .S.  589. 

Ill  "Xraite  ties  Maladies  du  Sein,"  p.  314. 

''-'  "  Science  and  Art  of  Surgery,"  vol  ii.,  1872,  p.  406. 


509 


CHAPTER   XXI. 

Non-malignant    Neoplasms    and   Cysts  of  the    Male 

Breast. 


The  present  state  of  our  knowledge  of  this  subject  warrants 
us  in  believing,  that  every  variety  of  neoplastic  disease  met 
with  in  the  female  breast,  has  also  its  counterpart  in  the  male 
breast ;  although  in  the  latter  these  morbid  manifestations  are 
of  great  rarity.  The  following  cases  suffice  to  illustrate  the 
truth  of  this  statement,  so  far  as  non-malignant  neoplastic 
diseases  are  concerned. 

8    I , Fibroma  and  Fibro-Adenoma. 

As  examples  of  pure  fibroma  I  know  only  of  the  two  sub- 
joined cases. 

(i)i  A  man,  aged  34,  with  a  hard  tumour,  the  size  of  a  walnut,  situated 
at  the  outer  side  of  the  nipple  of  his  left  breast.  It  was  of  four  months' 
duration,  and  arose  without  any  injury  or  other  known  cause.  During  the 
operation  for  its  removal,  it  was  found  to  be  partially  embedded  in  the  pec- 
toralis  major  muscle,  and  it  had  evidently  originated  from  the  posterior 
aspect  of  the  gland.  On  section  it  appeared  to  consist  of  dense,  whitish, 
fibrous  tissue,  which  centrally  presented  a  hyaline  appearance.  Histologi- 
cally it  was  composed  of  white,  fibrous  tissue,  in  which  at  the  periphery 
nuclei  were  abundant.     It  contained  no  glandular  structures. 

(2)^  In  this  case  a  hard  tumour,  two  and  a-half  inches  in  diameter,  was 
removed  from  the  breast  of  a  young  man  aged  18.  Histologically  it  con- 
sisted solely  of  dense,  white,  fibrous  tissue. 


'  Beadles,    Trans.  Path.  Soc.  Loud.,  1893,  P-  124. 
^  Virchow,  "  Path,  des  Tumeurs,"  t.  i.,  p.  329. 


5IO  non-malk;nant  neoplasms  of  the  male  breast. 

Some  cases  of  so-called  diffuse  fibroma  have  been  described, 
but  they  are  really  examples  of  chronic  mastitis.^ 

Fibro-adenoma  is  much  commoner  than  fibroma,  although  the 
number  of  cases  hitherto  recorded  is  by  no  means  large. 

Monro'  has  reported  the  case  of  a  labourer,  aged  27,  beneath  the  nipple 
of  whose  right  breast,  a  small  tumour  was  first  noticed  six  months  ago,  which 
followed  a  kick  there  six  months  previously.  On  examination  a  hard  circum- 
scribed, rounded,  lobular  tumour,  the  size  of  a  Tangeiine  orange,  presented 
beneath  the  nipple.  It  was  freely  mobile,  except  that  it  appeared  slightly 
held  in  the  vicinity  of  the  nipple.  There  was  no  pain  or  tenderness  asso- 
ciated with  it.  It  was  extirpated  together  with  the  overlying  skin.  The 
patient  was  soon  afterwards  convalescent.  Histologically  it  consisted  of 
dense  fibrous  tissue,  in  which  were  scattered  a  {&\\  tubular  glandular  struc- 
tures, lined  by  a  single  layer  of  columnar  epithelium. 

Paget*  mentions  a  case  of  this  kind,  which  occurred  in  the  person  of  a 
countryman,  25  years  old,  in  whose  breast  it  had  been  growing  for  five 
years.  After  removal  the  tumour  presented  as  an  encapsuled,  discoidal, 
slightly  lobulated  mass,  three  and  a-half  inches  in  diameter.  Histologically 
it  was  a  typical  fibro-adenoma. 

Velpeau"  has  reported  an  interesting  example,  in  which  a  large  lobulated 
cystic  tumour  of  this  kind  caused  ulceration  of  the  overlying  skin,  through 
which  it  projected.  The  patient  was  a  retired  army  surgeon,  aged  85.  The 
tumour  was  of  fifteen  years'  duration,  and  ulceration  began  three  years 
previously.  It  was  removed  by  ligation,  and  he  was  free  from  any  return 
of  the  disease,  when  he  died  of  some  other  cause  four  years  later. 

Cases  have  also  been  recorded  by  Roder,^  Le  Dentu/ 
Parona,^  Cruveilhier,^*^  and  others.^^ 

&     II. Villous  Papilloma. 

As  examples  of  this  disease  of  the  male  breast,  I  can  cite 
the  following  cases  : — 

(i)  In  the  Hunteritui  Mt/seian  (No.  4752  A.,  Path.  Series),  is  a  specimen 


=*  Bull,  de  la  Soc.  Anal.,  1888,  p.  42. 
'  Lancet,  vol.  ii.,  1892,  p.  368. 
^"Surgical  Pathology,"  vol.  ii.,   1853,  p.  258. 
"  "  Traitc  des  Maladies  du  Sein,"  p.  717. 

'  "  Beitrage  z.  Stat.  d.  Neubildungen  der  ii:aniilichen    Brustdriise,"  \.  D.,  Wiirz- 
burg,   1889,  S.  28. 

"  Bull,  et  A/chn.  de  la  Soc.  de  Clii?-.  de  J^aHs,  t.  xi.,  1885,  p.  900. 

"  Gaz.  Med.  Ital.-Lotnb.,  Milano,  1868,  No.  31,  p.  258. 

"  Traile  d'Anat.  Path.,  I.  iii.,  p.  54. 

"  Rev.  Med. -phot,  des  Hop.  de  Pans,  1874,  t.  vi.,  p.  137,  &c. 


VILLOUS    rAPTLLOMA.  5IT 

which  is  described  in  the  catalogue'-  as  follows  :  "  A  male  breast  showing  two 
oval  cysts  beneath  the  nipple  and  areola,  separated  by  a  thin  fibrous  septum, 
the  larger  one  measures  an  inch  in  its  longest  diameter.  Each  cyst  is  filled 
with  blood  clot.  The  specimen  was  removed  from  the  left  mammary  region 
of  a  man  aged  49,  who,  fifteen  years  previously,  first  noticed  a  few  drops  of 
brownish  discharge  escaping^  from  his  left  nipple.  This  continued  for  many 
years.  About  four  years  before  operation,  the  discharge  ceased,  and  the 
tumour  then  appeared." 

(2)'^  An  unmarried  man,  aged  30,  three  years  ago  noticed  some  slight 
irritation  about  his  left  nipple,  in  connection  with  which  shortly  afterwards, 
he  found  a  tumour,  the  size  of  a  hazel-nut.  Six  months  ago  it  was  only  half 
its  present  size.  On  examination,  a  large,  rounded,  elastic  tumour — twelve 
inches  in  circumference — occupied  his  left  mammary  region.  The  nipple 
had  almost  disappeared  through  stretching.  The  skin  over  the  most  pro- 
minent part  of  the  tumour  was  purplish  and  slightly  adherent,  otherwise  the 
tumour  was  freely  mobile.  There  was  no  enlargement  of  the  axillary 
glands.  On  exploratory  puncture  a  large  quantity  of  "  coffee-ground  "  fluid 
escaped.  The  breast  was  amputated.  On  examination  after  removal  the 
tumour  consisted  of  one  large  cyst  and  several  smaller  ones,  which  all  con- 
tained "coffee-ground"  fluid,  and  soft  reddish  pulp. 

(3)'^  A  married  man,  aged  55,  with  a  cystic  tumour,  the  size  of  an  orange, 
in  his  left  breast,  of  two  years'  duration.  On  examination  after  removal  a 
large  thin-walled  cyst,  filled  with  fluid  and  intra-cystic  villous  ingrowths. 

&     III. Lipoma. 

A  case  oi  diffuse  lipoma  of  both  mammary  regions  in  a  man  aged  29,  has 
been  reported  by  Baker  and  Bowlby.'^''  The  disease  was  of  one  year's  dura- 
tion. He  had  also  symmetrical  fatty  masses  on  each  side  of  the  front  of  the 
abdomen,  especially  in  the  supra-pubic  region,  in  each  scrotum,  and  at  the 
upper  and  inner  part  of  each  upper  limb.  He  was  a  great  drinker  of  gin 
and  beer. 

In  some  forms  of  gyntecomazia,  the  enlargement  is  often  mainly  due  to 
overgrowth  of  the  fatty  tissue  (ch.  iii.). 

An  example  of  a  large  fatty  tumour  of  the  male  mammary  region  was 
reported  by  Queirel  at  the  French  Surgical  Congress  in  1889."^ 

I  have  met  with  a  lipoma,  the  size  of  a  lady's  watch,  situated  two  inches 
below  the  left  nipple  of  a  man,  aged  })■})• 

S.  Paget''  has  seen  a  large  fatty  tumour  beneath  the  lower  part  of  the 
breast,  in  a  man  aged  35,  which  pushed  the  breast  forward  and  made  it 
seem  to  be  enlarged. 


'2  "Path.  Catalogue,"  Appendix  v.,  1891. 

"  De  Morgan,  Brit.  Med.  Jonriial,  vol  ii.,  1873,  p.  542. 

'^  Hewett,  Lancet,  vol.  ii.,  1863,  p.  482. 

'^  Med.  Chir.  Trans.,  vol.  Ixix.,  1886,  p.  41. 

'8  "  Proc.  verb.,"  1890,  t.  v.,  p.  671. 

'"  Lancet,  vol.  i.,  1894,  p.  1173. 


512    NON-MALIGNANT    NEOPLASMS    OF    THE    MALE    BREAST. 

S     IV. Chondroma. 

The  following  examples  have  been  recorded  : — 

(i)  In  Foucher's'^  case  a  large  tumour,  fixed  to  the  pectoral  muscle,  occu- 
pied the  mammary  region  of  a  man,  aged  35.  It  was  removed,  together  with 
a  portion  of  the  fifth  rib,  from  which  it  seemed  probable  that  the  tumour  really 
sprang.     The  patient  died  soon  afterwards  of  acute  suppurative  pleurisy. 

(2)  Seydel's'-'  case  is  an  example  of  osteo-chondro-sarcoma.  The  patient, 
a  young  man,  aged  22,  having  a  year  previously  sustained  an  injury  from  a 
fall,  and  subsequently  from  a  blow  on  the  same  spot,  soon  afterwards  noticed 
a  swelling  over  the  antero-lateral  part  of  the  eighth  right  rib.  In  the 
course  of  a  few  months  this  swelling  greatly  increased.  When  he  came 
under  observation,  a  large  rounded  tumour  projected  from  the  antero-lateral 
aspect  of  the  right  side  of  the  thorax.  It  reached  from  the  seventh  rib 
above  to  the  tenth  below,  and  laterally  it  extended  from  the  mid-axillary 
to  the  mammary  line.  An  attempt  at  excision  had  to  be  abandoned,  after 
removal  of  its  superficial  part  and  the  adjacent  ribs,  as  the  deep  part  of  the 
tumour  was  found  to  have  involved  the  liver.  Consequently  it  soon  grew 
up  again,  and  secondary  growths  appeared  in  several  of  the  ribs  higher  up. 
About  six  months  after  the  operation  the  patient  died,  the  disease  having 
involved  the  whole  of  this  part  of  thorax  from  the  sternum  to  the  scapula, 
and  from  the  nipple  to  near  the  iliac  crest.  There  were  secondary  growths 
in  both  lungs,  and  the  main  tumour  had  spread  by  direct  extension  to  the 
right  lung  and  liver.  The  peripheral  parts  of  the  primary  tumour  consisted 
of  sarcomatous  tissue  ;  while  more  centrally  only  newly  formed  cartilaginous 
and  osteoid  tissues  were  found.  The  secondary  growths  in  the  lungs  and 
liver  appeared  to  consist  only  of  osteo-chondromatous  structures. 

(3)  In  a  case  by  Virchow-"  an  osteo-chondromatous  tumour  the  size  of  two 
fists,  grew  from  the  thoracic  wall  of  an  old  man,  and  disseminated  in  the 
pleura  and  lungs.  Remarkable  features  of  this  growth  are,  that  Virchow 
could  detect  no  sarcomatous  tissue  in  it,  and  that  the  tumour  had  no  imme- 
diate connection  with  any  of  the  adjacent  ribs  ;  but  it  appeared  to  have 
sprung  from  the  soft  parts  of  an  adjacent  intercostal  space,  having  probably 
originated  from  some  belated  skeletal  sequestration. 

&    V, Angioma. 

(i)  A  labourer,  aged  17,  came  under  my  observation-'  with  a  considerable 
swelling  of  the  right  mammary  region,  of  congenital  origin.  On  examina- 
tion, I  found  a  softish,  discoidal,  lobulated  tumour,  three  and  a-half  inches  in 

'*  V Union  MM.,  1859,  No.  103,  p.  403. 

"•  Central./.  Chir.,  No.  56,  1890. 

20  ..  pajh   dcs  Tumeurs,"  t.  i.,  p.  533. 

*'  This  account  of  the  case  is  from  my  own  notes,  which  were  puhlished  in  the 
"Middlesex  Hospital  Surgical  Report,"  for  1887.  Sutton,  I  believe,  subsequently 
published  an  account  of  it  somewhere  or  other 


CYSTS.  513 

diameter,  involving  the  whole  of  the  mammary  region.  The  overlying 
nipple  was  stunted,  and  the  areola  ill  developed.  The  skin  above  the  areola 
presented  a  purplish  ncevoid  area.  Here  the  tumour  seemed  adherent  to 
the  overlying  skin,  elsewhere  it  was  freely  mobile.  About  three  inches 
below  the  nipple,  and  one  inch  to  its  inner  side  is  a  circumscribed  satellite 
tumour,  of  similar  character  to  the  main  one,  and  about  the  size  of  a  hazel, 
nut.  An  ill-defined  hard  cord  seems  lo  connect  the  two  tumours.  The 
glands  in  both  axillae  slightly  enlarged.  The  patient  otherwise  well  formed. 
He  said  that  soon  after  birth  a  lump,  the  size  of  a  walnut,  was  noticed 
beneath  his  right  nipple.  It  subsequently  became  red,  and  increased  in  size. 
It  has  since  slowly  increased.  The  nasvoid  condition  of  the  overlying  skin 
has  been  noticeable  as  long  as  the  patient  can  remember,  but  his  mother  says 
it  was  not  noticeable  at  birth.  No  family  history  of  moles,  njevi,  congenital 
deformity,  tumour,  or  cancer.  Breast  amputated  together  with  the  whole 
tumour  and  the  overlying  skin.  Free  haemorrhage.  On  examination  after 
removal,  a  cystic,  cavernous  nevoid  structure.  Histological  examination 
revealed  vascular  structures  mixed  with  fatty  tissue,  and  in  the  neighbour- 
hood of  the  nipple  mammary  glandular  tissue  was  found.  The  satellite 
nodule  was  composed  of  naevoid  tissue,  with  a  small  cyst,  containing  serous 
fluid,  embedded  in  it.     He  was  convalescent  a  month  later. 

I  have  seen  a  very  similar  tumour  also  in  a  man,  that  developed  in  con- 
nection with  a  congenital  n^evus,  situated  over  the  lower  antero-lateral  part 
of  the  thorax  on  the  right  side. 

(2)  Virchow"  cites  a  case  of  a  large  angioma,  occupying  the  left  pectoral 
region  of  a  male  child,  2  years  old. 

(3)  The  following  case  has  also  come  under  my  observation  :  A  male 
child,  aged  7  years,  with  a  discoidal  swelling,  the  size  of  half-a-crown, 
situated  an  inch  above  the  right  nipple  and  rather  internal  to  it.  It  was 
first  noticed  five  months  previously.  It  lies  nearly  over  the  intercostal 
space,  and  is  adherent  to  the  surrounding  parts.  Nipple  and  areola  well 
formed.  The  tumour  of  congenital  origin.  It  was  dissected  out  ;  a  thin- 
walled  cyst  containing  grumous,  yellowish  brown  fluid,  internally  smooth, 
externally  blended  with  adjacent  structures.  Beneath  it  the  intercostal 
muscles  deficient ;  a  process  of  the  cyst  seemed  to  have  projected  in  this 
direction  towards  the  pleura  ;  biJt  apparently  did  not  join  it.  The  cyst 
appeared  to  have  originated  from  a  degenerate  angioma.-^ 

§    VI. Cysts. 

There  are  on  record  a  larger  number  of  examples  of  cystic 
tumours  of  the  male  breast,  than  of  any  other  sexcept  cancer. 
The  following  case  was  observed  by  my  brother,  the  late  Dr.  J. 
A.  Williams,  and  the  account  of  it  is  from  his  notes. 


-'-  "  Path,  des  Tumeurs,"  t.  iv.,  p.  56. 

-■'  For  reference  to  a  case  of  cancer  developed  from  a  najvus  of  the  male  breast, 
vide  p.  315. 

3o 


514    NON-MALIGNANT  NEOPLASMS  OF  THE  MALE  BREAST. 

An  army  pensioner,  aged  72,  came  under  his  observation  with  a  rounded, 
slightly  lobulated  tumour,  the  size  of  a  small  orange,  beneath  his  left  nipple. 
It  was  circumscribed,  freely  mobile,  translucent  and  fluctuating.  The  nipple 
was  not  retracted,  nor  were  the  axillary  glands  enlarged.  On  pressure, 
yellowish  fluid  escaped  from  the  nipple,  which  under  the  microscope  showed 
cholesterine  scales,  epithelial  cells,  granular  cells  and  debris.  The  swelling 
in  the  breast  was  first  noticed  eighteen  months  ago,  after  a  blow.  No  family 
history  of  cancer  or  tumour.  The  tumour  was  excised  together  with  the 
overlying  skin.  On  examination  after  removal  a  single  thin-walled  cyst, 
containing  blood-stained  thin  fluid  ;  its  interior  smooth  and  shiny.  The 
wound  soon  healed.  The  cyst  had  evidently  originated  from  one  of  the  larger 
ducts. 

Velpeau-^  mentions  having  met  with  a  similar  cyst — the  size  of  an 
infant's  head — in  the  breast  of  a  boy  15  years  old. 

I  was  consulted  a  short  time  ago  by  a  gouty,  middle-aged  gentleman, 
whose  right  breast,  some  years  previously,  had  been  partially  removed  for 
cystic  disease  ;  he  now  came  to  me  with  an  enlargement  of  his  left  breast. 
On  examination  I  found  the  whole  organ  enlarged,  unduly  hard  and  tender, 
and  presenting  numerous  small  nodules,  as  if  due  to  multiple  cysts.  The 
nipple,  overlying  skin  and  axillary  glands  were  normal.  The  uneasiness 
and  tenderness  in  connection  with  it  subsided  under  the  influence  of  the 
extract  of  belladonna  and  iodide  of  lead  ointment.  It  was  probably  a  case 
of  general  cystic  disease  of  both  breasts  with  some  subacute  gouty  mastitis. 
Velpeau  has  reported  an  instance  of  a  large  cystic  tumour  of  the  breast 
of  a  man,  75  years  old.  It  was  of  nine  years'  duration,  and  contained 
lactescent  fluid.  By  Velpeau  it  was  regarded  as  a  \Q.x\\.'dh\&  galactocele.,  the 
only  case  of  the  kind  ever  signalised  in  the  male  sex. 

An  instance  of  sebaceous  cyst  of  the  areola,  on  the  verge  of  ulceration,  in 
a  man  has  been  seen  by  Birkett  ;-'  it  was  dissected  out  with  a  favourable 
result.     A  somewhat  similar  case  has  been  met  with  by  Burggraeve.-'^ 

A  man,  aged  39,  under  Billroth's-'  care,  had  a  hard,  lobulated  swelling, 
the  size  of  a  walnut,  under  his  right  nipple.  It  was  first  noticed  six  months 
ago.  On  examination  after  removal  a  multi-locular,  encapsuled  tumour, 
containing  dryish,  mortar-like  substance.  Billroth  thinks  it  probably  arose 
from  a  sebaceous  gland  of  the  areola.  It  appears  to  me  to  bear  more  resem- 
blance to  a  degenerated  angioma. 

In  the  Hiaiteriati  Museum  (No.  235,  Path.  Series)  is  a  specimen  of  a 
dermoid  cyst  of  the  male  breast,  with  the  following  description  by  Hunter 
himself:-*  "An  encysted  tumour  taken  from  the  breast  of  Mr.  Waters,  filled 
with  a  flaky  substance,  which  seemed  to  be  a  succession  of  cuticles,  being 
the  same  with  that  which  lines  it." 


-'  "Traite  des  Maladies  du  Sein,"  p.  717. 

-"■  "Holmes'  System  of  Surgery,"  vol.  iii.,  1883,  p.  460. 

-"  Bull,  de  la  Soc.  de  Med.  de  Gand.,  1857,  t.  xxiv.,  p.  160 

'•"  Deutsche,  Chir.,  Lief,  xli.,  S.  J  61. 

■'"  "  Path.  Cat.,"  vol.  i.,  1882,  p.  94. 


CYSTS.  515 

Another  specimen  of  a  dermoid  cyst  of  the  male  mamma  has  since  been 
added  to  the  Museum,'^  of  which  the  following  is  an  account. 

No.  256  B.,  of  the  Pathological  Series.  A  dermoid  cyst,  measuring  three 
inches  in  its  long  diameter,  and  flattened  from  side  to  side.  It  contains 
fatty  matter,  and  its  walls  are  formed  of  skin.  The  specimen  was  removed 
from  the  mammary  region  of  a  man,  aged  40,  where  it  was  situated  just  above 
the  left  nipple.  He  had  noticed  a  swelling  there  for  fifteen  years.  At  the 
same  time  that  this  cyst  was  removed,  a  smaller  one  of  similar  nature  was 
also  extirpated  from  the  right  infrascapular  region.  About  ten  years 
previously  other  similar  cysts,  first  noticed  at  the  ages  of  16  and  20,  had 
been  removed,  one  from  over  the  vei'tebra  prominens  and  another  from  the 
scalp. 


Path.  Catalogue,"  Appendix  i.,  1887,  p.  5. 


5i6 


CHAPTER  XXII. 

Axillary  Tumours. 


As  a  sequel  to  the  preceding  description  of  mammary  neo- 
plasms, it  seems  desirable  to  say  a  few  words  about  the  chief 
tumours  met  with  in  the  axilla. 

In  connection  with  the  axillary  integument,  moles,  ncevi, 
sebaceous  cysts,  inolluscum,  papilloma  and  epithelioma  may  arise. 

Bryant  mentions  two  instances  in  which  melanotic  sarcoma 
developed  from  moles  of  the  axillary  skin.^ 

The  following  example  of  dissemination  of  melanotic  sar- 
coma in  the  axillary  glands,  by  Carless,^  is  of  interest  as  showing 
the  course  of  lymphatic  infection. 

A  woman,  aged  54,  with  "melanotic  sarcoma"  of  the  skin  of  the  abdo- 
minal wall  of  two  years'  growth.  The  tumour  was  situated  midway  between 
the  xiphoid  appendix  and  the  umbilicus,  and  a  little  to  the  left  of  the 
median  line.  In  the  left  axilla  could  be  felt  two  enlarged  glands,  the  size  of 
pigeon's  eggs.  Below  and  to  the  inner  side  of  the  left  mamma  were  several 
small  melanotic  deposits,  evidently  due  to  lymphatic  dissemination.  The 
primary  growth  was  excised,  together  with  the  strip  of  skin  and  subcutaneous 
tissues  extending  from  it  to  the  axilla,  including  the  small  cutaneous  nodules 
below  the  breast  ;  and  the  axilla  was  cleared.  She  rapidly  recovered  from 
the  effects  of  the  operation. 

A  case  of  supposed  sarcoma  of  the  skin  of  this  part  was 

lately  brought  before  the  Clinical  Society  by  Bristowe.^ 

An  emaciated,  hectic  young  man,  aged  22,  with  the  skin  of  the  right 
axilla   and  adjacent  parts    of  the  chest  and  neck   extensively  invaded  by 

'  Q.v.  ch.  X..  §  ix.,  p.  308. 

-  Medical  Press  and  Circular,  vol.  i.,  1894,  p.  469. 

=*  Clin.  Soc.  Trans.,  1893. 


AXILLARY    TUMOURS.  517 

numerous  slightly  projecting  nodules,  from  a-half  to  one  and  a-half  inches 
in  diameter.  In  connection  with  some  of  these  nodes  deep  ulcers  had 
formed.  The  disease,  in  some  respects,  resembled  grajiuloma  fiingoides. 
Some  of  those  who  saw  the  lesions  thought  they  were  tubercular.  The 
patient  died  a  month  later  of  miliary  tuberculosis  of  the  lungs.  On  histo- 
logical examination  of  the  axillary  nodes  after  death,  they  presented  a 
sarcomatous  structure.  The  total  duration  of  his  illness  was  about  six 
months.  I  should  certainly  hesitate  to  accept  this  as  an  example  of 
sarcoma,  for  the  indications  seem  to  me  to  point  strongly  to  tubercle.  It 
is  highly  exceptional  to  find  active  tubercle  associated  with  any  form  of 
malignant  disease. 

In  pregnant  women  tumour-like  swellings  ("  the  axillary 
lumps"  of  Champney's)  not  unfrequently  form  in  connection  with 
hypertrophy  of  the  axillary  sebaceous  glands,  especially  during 
the  lactation  period,  when  they  often  furnish  lactescent  fluid. 
Chronic  inflammatory  conditions  ("  blind  boils,"  &c.)  arising 
in  connection  with  these  glands,  also  sometimes  give  rise  to 
tumour-like  swellings. 

Notwithstanding  the  great  number  of  sebaceous  glands 
connected  with  the  axillary  integument,  sebaceous  cysts  are  of 
remarkably  rare  occurrence.  Of  forty-five  consecutive  cases  of 
these  cysts  in  females  analysed  by  me,  not  one  was  axillary  ; 
and  of  fifty-five  cases  in  males,  there  was  only  a  single 
instance  of  sebaceous   cyst  of  this  part. 

In  the  case  referred  to  the  patient  was  a  married  man,  aged  30,  by  occu- 
pation a  painter.  He  had  noticed  a  lump  in  the  skin  of  his  left  axilla  for 
seven  years.  When  I  first  saw  him  he  had  a  suppurating  sebaceous  cyst 
there.     It  was  dissected  out,  and  he  was  well  a  few  days  later. 

Another  rare  affection  of  the  axillary  skin  is  epitJieliovia.  Of 
571  consecutive  cases  of  primary  skin  cancer  analysed  by  me — 
males  381,  females  190 — only  three  were  axillary,  two  males 
and  one  female. 

Subjoined  is  an  instance  of  this  condition  : — 

A  widow,  aged  79,  in  an  ill-nourished  and  demented  condition.  On 
examination  I  found,  at  about  the  middle  of  the  inner  wall  of  her  left  axilla, 
a  circular  sloughy  ulcer,  about  three  inches  in  diameter.  Its  edges  were 
raised  and  hard,  its  base  depressed,  hard,  and  covered  with  dirty  sloughs 
Surrounding  the  ulcer  is  an  indurated  zone  about  a-quarter  of  an  inch  in 
width.  This  indurated  mass  was  non-adherent  to  the  chest  wall.  The 
axillary  glands  were  markedly  enlarged.     The  only  history  I  could  gather 


5l8  AXILLARY    TUMOURS. 

was  that  there  had  been  some  disease  in  the  site  of  the  present  ulcer  for 
fifteen  years.  She  died  about  nine  weeks  later  of  acute  pericarditis.  At  the 
necropsy  the  condition  of  the  ulcerated  mass  was  much  as  at  admission.  On 
section  it  presented  as  a  dense  fibroid  growth,  about  half  an  inch  thick.  The 
axillary  glands  were  infiltrated  with  similar  disease.  No  other  second- 
ary growths.  Old  healed  tubercular  lesions  at  the  apex  of  each  lung. 
Visceral  and  parietal  layers  of  pericardium  greatly  thickened  and  shagj:;y 
from  recent  lymph  formation.  Old  thickening  of  auriculoventricular  valves. 
Extensive  atheroma  of  aorta.     Sloughs  at  back  of  both  heels. 

In  studying  axillary  tumours  it  is  important  to  bear  in  mind 
that  the  mammary  gland  sends  extensions  into  the  axilla,  which 
not  unfrequently  are  completely  sequestrated.  These,  under  the 
influence  of  pregnancy,  or  from  simple  inflammation,  often 
enlarge  ;  and  so  form  tumours,  which,  during  lactation,  may  dis- 
charge milk  through  one  or  more  pores.  In  this  connection 
cysts  may  arise,  containing  either  thin  mucoid  fluid  or  milk, 
either  pure  or  variously  altered.  Fibro-adenomatous,  sarco- 
matous and  cancerous  axillary  neoplasms  also  take  origin  from 
this  source.^ 

A  great  deal  of  interest  attaches  to  axillary  angioinata,  not 
only  on  their  own  account,  but  also  because  it  seems  probable 
that  most  congenital  axillary  cysts  arise  from  their  de- 
generation. 

A  good  example  of  a  large  tumour  of  this  kind  has  been 
reported  by  Osburne.^ 

An  ill-nourished,  puny,  female  child,  aged  lo  months,  came  under  his 
notice  with  a  rapidly  growing  angioma  of  the  left  axilla.  It  had  previously 
been  treated  by  passing  pins  under  it ;  after  which  it  increased  faster  than 
ever.  On  examination  an  angioma,  four  by  two  and  a-half  inches,  was  found 
occupying  the  whole  axilla,  and  extending  backwards  towards  the  scapula.  It 
was  dissected  out.  Several  large  vessels  connected  with  it  had  to  be  ligatured. 
The  wound  was  dressed  antiseptically,  and  it  soon  healed. 

McLeod"  has  recorded  the  history  of  a  male  Hindu,  aged  45,  who  came 
under  his  care  for  a  rapidly  increasing  axillary  tumour  of  two  months'  dura- 
tion. On  examination  the  left  axilla  was  found  to  be  filled  by  a  large,  tense, 
globular  swelling.     This  was  dissected  out.     It  was  found  to  communicate 


*  Vov  further  details  and  cases  vide  chap.  iv. ,  §  iv.  and  v. 

*  Lancet,  vol.  ii.,  1890,  p.  668. 

"  "  Operative  Surgery  in  Calcutta,"'  1885,  ji.  154. 


ANGIOiMA.  519 

by  numerous  branches  with  the  axillary  vein,  which  had  to  be  ligatured  and 
severed.     It  was  a  typical  angioma. 

A  healthy  woman,  aged  60,  came  under  Ormerod's'  notice  with  a  pedun- 
culated, pendulous  tumour,  the  size  of  the  fist,  hanging  from  the  lower  and 
inner  part  of  the  left  axilla.  It  was  of  dark  purplish  aspect,  hard,  knotty, 
and  distinctly  pulsatile.  It  had  existed  for  many  years,  but  of  late  its  in- 
crease had  been  unduly  rapid.  The  pedicle  was  ligatured  and  it  was  cut  off. 
On  examination  after  the  removal,  the  tumour  was  gorged  with  blood.  It 
consisted  of  a  mass  of  small  blood  vessels,  irregularly  arranged  and  of  varied 
sizes  ;  supported  by  a  small  quantity  of  fibrous  tissue. 

Busch^  has  described  the  case  of  a  woman,  aged  30,  with  a  non- pulsatile 
axillary  angioma,  the  size  of  a  pigeon's  egg,  that  was  first  noticed  when  she 
was  16  years  old. 

As  examples  of  cystic  tumours  derived  from  degenerate  angio- 
maia,  the  following  cases  are  instructive. 

(i)^  A  male  Hindu,  aged  23,  eight  months  before  coming  under  obser- 
vation, had  a  small  inflammatory  swelling  form  in  his  left  axilla,  which 
after  bursting,  left  an  ulcer  that  healed  slowly.  During  the  last  two  months 
a  rapidly  increasing  swelling  had  supervened  in  this  axilla.  On  examina- 
tion, McLeod  found  a  circumscribed  soft,  doughy,  mobile  tumour  there, 
which  extended  from  the  scapular  region  to  six  and  a-half  inches  above  the 
nipple.  It  was  rather  tender  on  manipulation.  In  attempting  its  removal 
by  dissection,  the  tumour  proved  to  be  intimately  connected  with  numerous 
adjacent  veins,  and  it  had  no  capsule.  The  patient  died  of  exhaustion  on 
the  third  day  after  the  operation.  On  examination  of  the  part  after  death,  a 
multilocular  cystic  structure  was  revealed,  composed  of  a  fibro-elastic  felt- 
work,  lined  with  flattened  epithelial  cells.  The  loculi,  for  the  most  part, 
varied  in  size,  from  a  sparrow's  &gg  to  a  walnut.  They  contained  a  glutinous 
fluid,  in  which  were  found  mucous  corpuscles,  degenerated  epithelial  cells, 
and  blood  corpuscles.  In  some,  parts  the  walls  of  the  loculi  were  thick  and 
solid  looking  ;  in  others  quite  thin.  On  section  the  growth  presented  a 
honeycomb  appearance. 

(2)  In  the  Hunterian  Museum  (No.  298  of  the  Pathological  Series)  is  a 
specimen  of  this  kind,  which  is  thus  described  in  the  catalogue.'"  "  A 
tumour  composed  of  a  collection  of  cysts  freely  mobile  under  the  skin,  and 
over  the  deeper  parts  that  filled  the  hollow  of  the  axilla.  Its  walls  were 
fibrous  ;  and  its  contents  a  granular  pulpy  magma." 

Other   cases    have    been    recorded    by    Hawkins,    Guersant, 
Birkett,  Trendelenburg,  Liicke,  &c. 


'  Cited  by  Paget,   "  Lectures  on  Surgical  Pathology,"  vol.  ii.,  1S54,  p.  276. 

*  "  Chir.  Beobachtungen, "  S.  213. 

'  McLeod's  "  Operative  Surgery  in  Calcutta,"  Pi.  88,  p.  149. 

'"   "General  Pathology  Catalogue,"  vol.  i.,  1882,  p.  11. 


520  AXILLARY    TUMOURS. 

Hawkins''  was  one  of  the  first  who  clearly  pointed  out  the  origin  of  these 
cystic  tumours  from  degenerate  ntevi.  In  one  of  his  cases,  a  congenital 
axillary  tumour  of  this  kind  sent  prolongations  into  the  neck  and  arm. 

In  Guersant's'-  case,  a  boy,  3  years  old,  came  under  treatment  for  a 
congenital  tumour  at  about  the  middle  of  the  anterior  border  of  the  axilla. 
It  was  extirpated.  On  examination  after  removal,  the  tumour  looked  like  a 
cardiac  auricular  appendix.  On  section  it  consisted  of  several  cysts  con- 
taining sanio-serous  fluid. 

Of  Birkett's"'^  cases,  the  first  was  a  man,  aged  28,  from  whose  axilla  a 
congenital  cystic  tumour  of  this  kind  was  successfully  extirpated.  His 
second  was  a  male  child,  7  years  old,  who  had  a  cyst  of  this  kind  that 
occupied  the  right  axillary  and  subscapular  regions  ;  and  was  first  noticed 
six  years  previously.  In  the  third  case  the  patient  was  a  man,  aged  20,  in 
the  lower  part  of  whose  neck,  on  the  right  side,  a  cystic  swelling  was  first 
noticed  soon  after  birth,  which  gradually  extended  into  the  axilla.  When 
only  3  years  old  it  was  tapped,  and  several  ounces  of  quasi-serous  fluid  were 
withdrawn  ;  but  it  soon  refilled.  An  immense  cystic  tumour  subsequently 
developed,  which  now  occupied  the  whole  axilla  and  the  lower  part  of  the 
neck.  It  was  repeatedly  tapped,  and  in  all  181  ounces  of  dark  brown  fluid 
were  withdrawn,  but  it  soon  filled  again. 

In  Trendelenberg's'*  case,  a  boy,  one  day  old,  had  a  large  cystic  tumour 
of  the  neck,  which  sent  a  prolongation  into  the  axilla.  It  was  cured  after 
three  iodine  injections. 

Liicke's''  patient,  a  boy  aged  7  weeks,  with  a  congenital  tumour  of  the 
right  axilla,  which  extended  also  over  the  adjacent  part  of  the  thoracic  wall. 
The  overlying  skin  presented  some  telangiectatic  tacJies.  On  section  after 
removal,  it  presented  a  multilocular  structure,  in  vascular  communication 
with  the  subclavian  vein. 

The   case    I  am    about  to    relate  is  a  good  example  of  a 

congenital  multilocular  axillary  cyst  of  nsevoid  origin. 

A  female  child,  aged  8  weeks,  otherwise  well  formed  and  healthy,  came 
under  the  observation  of  my  brother,  the  late  Dr.  J.  A.  Williams,  with  a  large 
soft,  lobulated  tumour  in  the  right  axilla.  The  mother  said  she  had  noticed 
a  swelling  in  the  child's  axilla  ever  since  birth.  It  was  then  about  the  size 
of  a  walnut.  It  had  increased  very  rapidly  during  the  last  few  weeks.  No 
injury  or  other  known  cause.  The  mother  has  had  twelve  other  children, 
none  of  whom  had  similar  tumours,  or  were  otherwise  deformed  ;  four  of 
them  are  now  alive   and  well,  the    others    have    died  of  various  infantile 

"  Med.  Chir.  Trans.,  vol.  xxii.,  p.  231.  "On  a  peculiar  form  of  Congenital 
Tumour  of  the  Neck." 

'-  Gaz.  Hehd.  de  Med.,  1855,  p.  39S.  "  Sur  ics  Kystes  dcveloppcs  dans  les 
tumeurs  erectiles  veineuses  enflammees. " 

'■'  Med.  Chir.  Trans.,  l858,  p.  185,  "  A  Contrilnition  to  the  Surgical  Pathology 
of  .Sero-santjuiiieous  Cysts  in  the  Neck  and  Axilla." 

'^  Arch.  f.  klin.  Chir.,  1871,  Bd.  xiii.,  S.  404. 

'■'  Pitha  and  Billroth's  "  Handb.  d.  alleg.  u.  spec.  Chir,,"  Bd.  ii.,  S.  284. 


CVSTOMA, 


521 


diseases.  She  has  also  had  one  miscarriage.  The  birtli  of  the  patient  was 
easy  and  natural.  On  examination  the  child's  right  axilla  is  occupied  by  a 
large,  bossy,  pyramidal  tumour,  which  measures  about  five  and  a-half  inches 
in  its  long  diameter  (fig.  71).  It  fluctuates  and  is  translucent.  Several 
unduly  enlarged  subcutaneous  veins  can  be  seen  coursing  over  the  tumour. 
It  was  tapped  in  several  places,  and  about  six  ounces  of  pale  yellow  fluid 
were  evacuated.  On  standing  this  clotted,  and  after  a  time  separated  into 
gelatinous  clot,  and  pale  serous  fluid.  The  fluid  coming  from  the  cyst  con- 
tained so  much  albumen  that  it  solidified  on  boiling  :  it  contained  no  sugar. 


Fig.  71. — A  congenital  multi-locular  cystoma  of  the  axilla. 


The  fluid  that  remained  after  clotting  was  also  highly  albuminous.  This  fluid 
was  contained  in  distinct  loculi,  so  that  a  considerable  quantity  of  it  could 
only  be  obtained  by  numerous  tappings  in  different  places.  Even  after  this 
the  tumour  did  not  entirely  disappear.  A  fortnight  later  it  was  as  large  as 
ever  again.  It  was  again  tapped  in  several  different  places,  and  this  time 
the  fluid  that  escaped  was  blood  stained.  A  month  later  the  cysts  had 
again  refilled,  and  were  evacuated  again.  Three  weeks  later  the  tumour 
was  larger  than  ever.  Setons  were  now  passed  through  it,  which  excited 
free  suppuration.  A  month  later  —  the  tumour  having  shrunk  to  the 
size  of  a  walnut — the  patient  died,  apparently  from  exhaustion.  At  the 
necropsy  the  tumour  was  quite  small,  and  contained  only  about  a  drachm 
of  pus.  It  had  no  communication  with  the  chest  wall,  pleura  or  neck.  The 
various  internal  organs  were  healthy. 

It    occasionally    happens    that  degenerate    naevoid    tumours 
give  rise  to  unilocular  cysts,  as  in  the  two  following  cases : — 


52  2  AXILLARY    TUMOURS. 

(i)'^  A  woman,  aged  26,  eighteen  months  ago,  first  noticed  a  swelling — 
the  size  of  a  walnut — in  her  right  axilla.  In  the  course  of  a  year  it  attained 
the  size  of  an  orange,  when  it  was  twice  aspirated.  Three  months  later  she 
was  confined ;  and  the  cyst  rapidly  increased  to  the  size  of  a  cocoa-nut,  the 
skin  over  it  becoming  red,  and  the  subcutaneous  veins  much  distended.  It 
was  then  tapped,  and  thirty-two  ounces  of  brownish  fluid  were  evacuated. 
This  was  twice  repeated  at  intervals  of  about  a  week,  thirty  and  sixteen 
ounces  of  fluid  being  drawn  off  on  these  occasions.  Each  time  the  fluid 
thus  obtained  was  more  blood-stained.  About  a  fortnight  after  the  last 
tapping,  the  cyst  having  filled  again,  the  whole  mass  was  dissected  out.  It 
was  found  to  be  a  single,  thin-walled  cyst,  firmly  fixed  to  the  subcutaneous 
tissues  at  the  upper  part  of  the  axilla. 

(2)  In  the  Htmteriaii  Museuni''^  (No.  297  of  the  Pathological  Series)  is 
a  specimen  of  a  large  cyst  from  the  axilla  of  a  man,  aged  35,  which  con- 
tained three  and  a-quarter  pints  of  turbid  yellowish,  highly  albuminous 
fluid,  in  which  was  much  granular  matter  and  cholesterine.  Its  wall  is  of 
fibrous  tissue,  lined  internally  by  a  layer  of  smooth  granulations. 

The  resemblance  between  such  cases  as  the  foregoing,  and  the  large 
axillary  cysts  described  by  T.  Smith,"*  is  so  close  as  to  suggest  similarity  of 
origin. 

A    few  examples  of  lymph-angioma  of  the   axilla  and    its 

vicinity  have  been  recorded. 

In  a  boy,  4  years  old,  Pinner'*  met  with  a  case  of  this  kind.  There  was  a 
congenital  multilocular  tumour  at  the  lower  part  of  the  left  axilla,  which 
contained  fluid  of  varied  nature.  It  was  cured  after  two^^fappings,  followed 
by  injection  with  3  per  cent,  solution  of  zinc  chloride. 

Miiller'-"  has  reported  a  case  of  congenital  cystic  lymph-angioma  of  the 
right  axilla,  that  extended  also  down  the  right  side  of  the  trunk,  in  a  male 
child,  one  year  old.     Extirpation  was  followed  by  rapidly  fatal  collapse. 

Wegner-'  has  successfully  extirpated  a  congenital  cystic  lymph-angioma 
from  the  right  side  of  the  thorax  of  a  boy,  nine  months  old. 

Godlee^^  has  related  a  curious  case,  in  which  a  suppurating 
intra-thoracic  dermoid  cyst  pointed  in  the  axilla,  where  it  was 
opened.  It  discharged  pus  and  hairs  ;  and  its  wall  resembled 
cutis  vera.  The  patient  was  a  woman,  aged  30,  with  symptoms 
of  pulmonary  abscess. 

The  axilla  is  an  occasional  seat  for  the  development  of  lipo- 


'*  St.  Barfs.  Hasp.  Reports,  vol.  xxiv.,  1888,  p.  304. 
"  "General  Pathology  Catalogue,"  vol.  i.,  1882,  p.  in. 
'*  Clin.  Soc.  Trans.,  vol.  xiii.,  p.  197. 

''■•  "  Ein  Fall  von  Lymph-angioma  cystoides,"  &c.,  Cent.  f.    Chir.,  1880,  Bd.  ix.. 
S.  177. 

•la  «'2iur  Casuistik  der  Lymph-angiome,"  Cent.  f.  Chir.,  18S5,  S.  356. 
■i\  <«  Ueber  Lymph-aiigiome,"  Arch.  J.  klin.  Chir.,  Bd.  xx.,  S.  641. 
*2  JWed.  Chit.  Jrans.,  1889. 


LIPOMA.  523 

viata.  Of  190  consecutive  lipomata  analysed  by  me,  males  59, 
females  131,  10  were  situated  in  the  axilla,  males  3,  females  7. 
In  this  situation  lipomata  sometimes  assume  the  polypoid  form. 
The  following  cases  have  come  under  my  notice  : — 

(i)  A  well-nourished,  dark-complexioned  servant  girl,  aged  19,  with  a 
h)bulated,  soft  subcutaneous  tumour,  the  size  of  half  an  orange,  just  within 
the  posterior  fold  of  the  right  axilla,  at  its  lower  part.  The  breast  and 
nipple  normal.  A  swelling  in  this  situation  was  first  noticed  two  years  ago. 
No  injury  or  other  known  cause.  Catamenia  first  at  13,  and  since  regular. 
She  was  born  in  London.  Previous  health  good  ;  no  serious  illness,  except 
rheumatic  fever  at  14.  Her  mother's  sister  died  of  internal  cancer.  The 
tumour  was  dissected  out,  and  it  proved  to  be  a  typical  lipoma.  The  wound 
healed  slowly,  and  nineteen  days  after  the  operation  a  small  sinus  still  re- 
mained. As  this  did  not  close  of  itself,  it  was  scraped  ten  days  later. 
About  a  fortnight  afterwards  the  sinus  had  quite  healed. 

(2)  A  well-nourished,  healthy  looking  married  woman,  aged  2)^1  with  a 
pedunculated  subcutaneous  tumour,  hanging  from  the  middle  of  the  anterior 
fold  of  the  right  axilla.  She  had  noticed  it  for  three  years.  It  was  excised, 
and  proved  to  be  an  ordinary  encapsuled  lipoma.     The  wound  soon  healed. 

(3)  A  widow,  aged  41,  engaged  in  the  nursery.  Married  at  21,  and  the 
mother  of  two  children,  widowed  at  26.  An  obese,  dark-complexioned 
woman.  Three  years  ago  she  first  noticed  a  small  swelling  in  the  site  of 
present  disease.  On  examination  I  found,  over  the  middle  of  the  anterior 
fold  of  the  right  axilla,  a  rounded,  projecting,  lobulated,  soft  tumour,  the 
size  of  a  large  walnut.  No  injury  or  other  known  cause.  No  family  history 
of  tumour,  cancer,  or  tubercle.  Her  previous  health  had  been  good.  It  was 
dissected  out.  An  ordinary  subcutaneous  lipoma.  In  about  a  fortnight's 
time  the  wound  had  quite  healed. 

(4)  A  dark-complexioned,  obese  multipara,  aged  46.  Seven  years  ago 
she  first  noticed  a  swelling  in  site  of  present  disease.  It  came  without 
injury  or  other  known  cause.  Previous  health  good.  No  family  history  of 
tumour,  cancer  or  tubercle.  At  the  upper  part  of  the  anterior  border  of  the 
left  axilla  is  a-  soft,  lobulated,  circumscribed,  mobile  swelling.  Breast  and 
nipple  normal.  Dissected  out.  A  typical  subcutaneous  lipoma.  The 
wound  had  quite  healed  in  three  weeks'  time. 

(5)  A  well-nourished,  healthy  looking  married  woman,  aged  31,  with  a 
rather  firm,  lobulated,  elastic,  freely  mobile  tumour,  situated  immediately 
under  the  skin,  over  the  anterior  fold  of  the  right  axilla.  Her  brother  has  a 
lipoma  of  his  back.  Her  mother  died  of  cancer  of  the  breast.  No  injury 
or  other  known  cause.  Previous  health  good  ;  typhoid  fever  six  years  ago. 
A  lump  was  first  noticed  in  the  site  of  the  present  tumour  two  years  ago.  It 
was  dissected  out,  and  proved  to  be  a  fibro-lipoma.  The  wound  was  quite 
healed  two  weeks  later. 

(6)  A  healthy  multipara,  aged  32,  with  a  subcutaneous  tumour,  over  the 
middle  of  the  posterior  fold  of  her  right  axilla.  It  was  soft,  lobulated  and 
freely  mobile.  She  attributed  it  to  a  strain  in  lifting  a  heavy  weight,  two 
years  ago.      No   family    history   of  tumour,    cancer    or  tubercle.      It    was 


524  AXILLARY    TUMOURS. 

dissected   out.     An  ordinary  lipoma.     The  wound  had  healed  a  fortnight 
later. 

Fatty  tumours  that  originate  in  the  neck  and  other  adjacent 
parts  sometimes  extend  into  the  axilla. 

Sarcomatous,  myxomatous  and  fibromatous  tumours  also  arise 

from  the  axillary  connective  tissue ;  but  they  are  very  rare. 

Erichsen-'^  figures  an  example  of  fibro-sarcoma  of  the  right  axilla  of  a 
woman,  that  presented  as  a  large,  smooth,  rounded  tumour,  of  very  slow 
growth.     It  originated  beneath  the  serratus  inagnus  muscle. 

Chondromatous  and  ossiform  tumours  of  the  axilla  generally 
spring  either  from  the  upper  end  of  the  humerus,  or  from  the 
coracoid  process  (Dolbeau).     They  are  great  rarities. 

The  majority  of  axillary  tumour-like  swellings  are  due  to 
enlarged  lymph  glands.  Most  of  these  are  either  the  outcome 
of  chronic  inflammatory  conditions,  associated  with  tubercle,  or 
they  are  secondary  to  some  lesion  of  the  upper  extremity  or  adja- 
cent parts  within  the  zone  of  the  axillary  lymphatics.  Under 
these  circumstances  several  glands  are  usually  affected.  In  other 
instances  one  or  more  glands  enlarge  without  any  obvious  cause 
— simple  lymphoma.  Such  enlargements  may  be  strictly  local, 
or  they  may  form  part  of  a  general  lymphadenosis,  with  or  with- 
out leucocythaemia  and  splenic  affection.  Winiwarter  maintains 
that  there  is  a  sharp  distinction  between  hyperplastic  lymphatic 
tumours  of  this  kind,  and  primary  sarcoma  starting  from  lymph 
glands,  which  may  be  either  of  the  round  or  spindle  celled 
variety.  After  a  short  time  lympho-sarcomata  generally  infil- 
trate the  surrounding  structures  ;  and  they  often  disseminate  in 
the  lungs,  liver  and  spleen.  They  tend  to  run  a  rapidly  fatal 
course.  All  kinds  of  lymph-glandular  tumours  may  come  into 
close  relationship  with  the  large  vessels  and  nerve  cords.  They 
are  known  by  their  smooth,  ovoid  shape,  and  their  elastic  con- 
sistence ;  but  chiefly  by  reason  of  their  position  in  the  localities 
where  glands  normally  exist. 

Other  sources  of  axillary  tumour-like  swellings  are  chronic 
abscesses  (mostly  of  lymph-glandular  origin),  aneurism,  and 
ruptured  blood  vessels. 

-'  '*  .Science  and  Art  of  Surgery,"  vol.  ii.,  1872,  p.  503. 


525 


CHAPTER  XXIII. 

Inflammation  and  Suppuration. 


S    I. Mastitis  and  Microbes. 

Before  entering  on  the  study  of  inflammatory  diseases  of 
the  breast,  it  seems  desirable  briefly  to  set  forth  the  chief  facts 
relating  to  the  rather  recently  established  conclusions,  as  to  the 
connection  between  these  diseases  and  micro-organisms.  By 
modern  pathologists  inflammation  is  regarded  as  a  reaction  of 
the  organism,  provoked  by  the  presence  of  microbes  in  the 
tissues,  which  it  is  destined  to  neutralise  or  destroy.  According 
to  the  old  ideas,  the  acute  inflammations  of  the  breast  asso- 
ciated with  lactation,  were  attributed  to  engorgement  of  the 
glandular  structures  with  stagnant  milk.  But  recent  experi- 
ments have  shown,  that  when — in  suckling  animals — the  out- 
flow of  milk  is  artificially  prevented,  no  inflammation  follows 
unless  the  milk  contain  an  abundance  of  microbes. 

Numerous  investigations  point  to  the  conclusion,  that 
nearly  all  forms  of  mammary  inflammation  are  consequent  on 
the  presence  within  the  ducts,  &c.,  of  irritant  substances  of 
microbic  origin.  Hence  the  morbid  process  almost  invariably 
first  manifests  itself  in  the  immediate  vicinity  of  these  struc- 
tures. The  possible  exception  to  this  rule  is  in  the  case  of 
cutaneous  erysipelas,  secondarily  spreading  to  the  breast,  when 
the  microbes  are  believed  to  enter  the  organ  by  way  of  the 
lymphatics.      But  even    in    a    case    of  this    kind    Billroth    and 


526  INFLAMMATION    AND    SUPPURATION. 

Ehrlich^  found  the  ducts,  &c.,  distended  with  micrococci.     This 
may,  however,  have  been  due  to  mixed  infection. 

That  pathogenic  microbes  may  exist  in  the  healthy  body 
without  necessarily  exciting  disease,  is  now  generally  believed. 
To  this  rule  the  breast  is  no  exception.  .  Palleske^  has  de- 
monstrated that  milk  fresh  from  the  breasts  of  healthy  women, 
frequently  contains  pathogenic  microbes,  chiefly  staphylococcus 
pyogenes  albiLS.  This  enables  us  to  understand  the  occasional 
temporary  occurrence  of  foetid  milk  in  the  mammae,  of  which 
Jorissenne-^  has  recorded  the  following  instance  : — 

A  woman  of  rather  tubercular  aspect,  though  in  good  health,  having 
freely  suckled  her  child  for  about  three  months,  was  then  one  day  absent 
from  it  for  seven  and  a-half  hours.  During  this  time  she  was  walking 
for  five  and  a-half  hours,  driving  for  another  hour,  and  only  one  hour  was 
allowed  for  rest  and  refreshment.  On  her  return  home  the  milk  was  so 
fcEtid,  that  when  she  commenced  suckling  her  friends  could  hardly  remain 
in  the  same  room  with  her.  The  child  nevertheless  sucked  greedily, 
although  it  was  sick  afterwards.  Next  day  her  milk  was  quite  sweet  again, 
and  there  was  no  sign  of  inflammation  of  the  breast,  nor  of  any  disturbance  of 
the  general  health.  The  patient  said  that  on  several  previous  occasions, 
under  similar  circumstances,  she  had  noticed  transitory  foetidity  of  her  milk. 

It  is  an  important  matter  to  determine  how  microbes  enter 
the  breast.  Most  pathologists  believe  that  they  pass  into  it 
from  the  cutaneous  surface,  through  the  galactophorous  ducts, 
and  they  point  to  the  frequency  with  which  inflammations  and 
abscesses  arise  in  the  lower  segment  of  the  gland,  as  evidence 
in  favour  of  this  view.  Under  these  circumstances  the  patho- 
genic germs  arc  probably  derived  from  the  child's  mouth,  or 
from  the  hands,  &c.,  of  the  mother — contaminated  with  lochial 
discharges.  The  number  of  micro-organisms — many  of  them 
pathogenic  —  that  find  a  suitable  habitat  in  the  mouth  is 
immense. 

It  has  been  proved  that  microbes  having  entered  the  blood, 
are  often  eliminated   by  the  secretions,  especially  by  the  urine. 


'  Arch.f.  klin.  Chir.,  Bd.  xx.,  S.  418. 

^  Arch.f.  path.  Anat.,  Bd.  cxxx.,  1892,  S.  185. 

"  Arch,  de  Toe.  et  de  Gyn.,  fev.,  189 1. 


MASTITIS    AND    MICROBES.  527 

In  like  manner,  Escherich*  believes  that  microbes  associated 
with  puerperal  septic  conditions,  which  enter  the  blood  through 
lesions  connected  with  the  genital  tracts,  often  find  their  way 
into  the  milk.  Hence  the  necessity  of  keeping  the  genital 
passages  thoroughly  aseptic,  in  order  to  avoid  this  source  of 
infection. 

In  1884,  Bumm^  demonstrated  the  presence  of  microbes  in 
the  milk  of  women  suffering  from  puerperal  mastitis.  From  a 
case  of  this  kind  he  cultivated  a  diplococcus,  much  like  the  gono- 
coccus  ;  and  the  culture,  when  injected  under  his  own  skin,  pro- 
duced an  abscess.  In  women  suffering  from  this  affection, 
Escherich  found  that  the  milk  invariably  contained  numerous 
specimens  of  stapJiylococcus  pyogenes  aureus  or  albiis.  In  con- 
tinuation of  his  previous  investigations  Bumm^  also  found  in 
cases  of  this  kind,  that  the  glandular  structures  teemed  with 
staphylococci,  which  made  their  way  thence  into  the  surrounding 
tissues.  By  studying  numerous  sections  removed  at  different 
stages  of  the  disease,  he  was  able  to  give  the  following  account 
of  the  morbid  process  : — The  rapid  proliferation  of  the  microbes 
within  the  glandular  structures,  causes  the  milk  to  ferment, 
its  sugar  being  transformed  into  lactic  and  butyric  acids,  while 
its  casein  coagulates.  Thus  the  glandular  structures  become 
filled  with  coagula, teeming  with  bacteria.  Inflammatory  changes 
soon  manifest  themselves  in  the  peri-glandular  tissues,  which 
become  infiltrated  with  leucocytes  and  microbes.  Meanwhile 
the  epithelial  cells  lining  the  glandular  structures  swell,  des- 
quamate and  disappear.  Purulent  miliary  foci  soon  form  in 
great  numbers,  adjacent  foci  unite,  and  so  irregular  purulent 
cavities  are  formed,  traversed  by  shreds  of  the  partially  destroyed 
tissues.  In  the  walls  of  these  suppurating  cavities  leucocytes 
accumulate,  which  stop  the  progress  of  the  microbes,  and  thus 
the  further  spread  of  the  disease  is  prevented. 


■»  Fortschritte  der  Medecin,  Bd.  iii.,  1885,  S.  231. 
^  Arch.f.  Gyn.,  Bd.  xxiv.,  1884,  S.  262. 
"  Sammluug  kliii.   Vorirdge,  No.  282,  1886. 


528  INFLAMMATION    AND    SUPPURATION. 

In  a  case  of  puerperal  mastitis,  followed  by  fatal  pyaemia, 
in  which  the  breast  was  riddled  with  abscesses,  Grosse^  found 
staphylococcus  pyogenes  mireus  and  albiis  present  in  great  abund- 
ance. Brieger,  Rosenbach,  Pawlowsky  and  others  believe  that 
these  cocci,  considered  by  some  pathologists  to  be  comparatively 
harmless,  may — under  certain  conditions — induce  pyaemia. 
According  to  Monnier,*^  most  post-puerperal  abscesses  of  the 
breast  are  due  to  the  presence  of  staphylococci,  either  alone  or 
associated  with  other  microbes,  such  as  viicivcoccus  tetragemis, 
streptococcus  or  micrococcus  subflaviis. 

It  will  be  gathered  from  the  foregoing  that  in  human 
beings  there  is  no  specific  microbe  of  mastitis,  for  several 
different  pathogenic  organisms  have  the  power  of  inducing  the 
disease. 

It  appears  to  be  otherwise  in  some  animals,  for  Nocard  and 
Mollereau^  have  shown  that  the  contagious  forms  of  mastitis  of 
milch  cows  and  sheep,  are  due  to  specific  organisms.  These 
observers  have  proved  that  in  cows  the  disease  is  due  to  the 
presence  of  a  streptococcus  within  the  glandular  structures,  which 
it  never  leaves.  Consequently  the  resulting  inflammatory  re- 
action is  limited  to  the  peri-glandular  tissues,  so  that  multiple 
nodulations  are  formed.  The  lesions  thus  produced  in  many 
respects  resemble  those  met  with  in  certain  forms  of  diffuse, 
peri-ductal  chronic  mastitis  in  human  beings.  On  the  other 
hand,  in  sheep  the  disease  assumes  the  form  of  an  acute  diffuse 
suppurative  inflammation,  which  often  quickly  leads  to  gan- 
grene and  death.  In  these  cases  Nocard  found  very  minute 
micrococci  both  in  the  milk  and  in  the  fluid  of  the  oedematous 
adjacent  tissues.  These,  he  believes,  enter  the  gland  by  the 
ducts,  and  rapidly  penetrate  into  the  surrounding  parts.  The 
condition  thus  produced  much  resembles  the  acute  difl"use  sup- 
purative mastitis  of  puerperal  women. 


'  Cent./.  Gyn.,  No.  34,  1892. 

"  7'h^se  lie  Farts,  1891. 

'•"  "  Annales  de  I'lnbtitul  Pasteur,"  1887,  p.  109  and  p.  417. 


CHRONIC    MASTITIS.  529 

vj    11. Chronic  Mastitis. 

Chronic  inflammation  of  the  breast  may  involve  the  whole 
organ  {diffuse) ;  it  may  be  limited  to  the  vicinity  of  the  glan- 
dular structures  {peri-dnctal) ;  or  only  a  small  segment  of  the 
organ  may  be  affected  {circiimscribed).  This  classification  is 
clinically  useful,  but  it  must  be  remembered  that  all  sorts  of 
intermediate  and  mixed  forms  may  be  met  with.  In  all  these 
cases  the  probable  cause  of  the  disease  is  the  presence  of 
microbes,  or  of  irritant  substances  of  microbic  origin,  within  the 
glandular  structures.  Consequently  the  morbid  process  almost 
invariably  originates  in  their  immediate  vicinity. 

A.  The  diffuse  form  of  chronic  mastitis  was  first  clearly 
described  by  Wernher,^°  over  forty  years  ago.  He  recognised 
the  initial  painful  enlargement,  the  subsequent  induration,  and 
the  final  irregular  atrophy.  On  account  of  the  likeness  of  the 
disease  to  cirrhosis  of  the  liver,  he  called  it  cirrhosis  inammce. 
Cruveilhier^'  also  was  familiar  with  the  disease,  and  he  was  well 
aware  that  in  its  atrophic  stage  it  is  often  difficult  to  distinguish 
it  from  cancer,  a  feature  to  which  Phocas^^  and  others  have 
lately  called  attention.  By  Velpeau^^  it  was  briefly  described 
under  the  title  of  induration  chronique  en  masse.  In  his  great 
work  on  tumours,  Virchow^^  has  given  an  excellent  account  of 
the  disease,  which  he  calls  "  diffuse  fibromal'  or  "  hard  elepJian- 
tiasis." 

Chronic  mastitis  has  lately  attracted  a  great  deal  of  attention 
in  connection  with  its  bearing  on  the  question  of  the  inflam- 
matory origin  of  general  cystic  disease,  and  even  of  fibro-adeno- 
mata.  The  tendency  of  modern  pathologists  to  resurrectionise 
the  doctrine  of  Rroussais  in  connection  with  the  microbe  theory, 
is  one  of  the  signs  of  the  times  ;    and  it   invariably  crops   up 


'"  Zeiisckr.f.  rat.  Medicin.,  1851,  Bd.  x.,  S.  153. 

'•  "Traite  d'Anat.  path.,"  t.  iii.,  p.  605. 

'-  Gaz.  des  Hopitaitx,  19  aout,  1890. 

'•''  Traite  des  Maladies  du  Sein,  &c.,  p.  255. 

'<  "  Path,  des  Tumeurs,"  t.  i.,  p.  325 


34 


530 


INFLAMMATION    AND    SUPPURATION. 


whenever  any  question  relating  to  neoplastic  pathogeny  is  under 
consideration. 

The  initial  symptoms  of  the  disease  are  those  of  subacute 
inflammation.  At  first  there  is  tenderness  and  swelling,  which 
may  begin  by  involving  the  whole  gland,  or  it  may  start  from  a 


Fig.  72. — Chronic  cirrhosing  mastitis  {Billroth). 


circumscribed  focus  and  subsequently  spread  to  the  rest  of  the 
organ.  After  a  time  the  affected  part  becomes  hard  and  painful, 
but  there  are  no  febrile  symptoms.  The  morbid  process  often 
involves  not  only  the  whole  gland,  but  also  the  paramammary 
fatty  tissue,  the  overlying  skin  and  even  the  nipple.     Where  the 


CHRONIC    MASTITIS.  53 1 

skin  is  affected  it  seems  adherent,  thickened  and  rough  looking- 
— what  the  French  call  peaii  d'orange.  By-and-bye  the  inflam- 
matory tissue  contracts,  the  swollen  part  diminishes  in  size  and 
increases  in  density.  As  the  contraction  is  irregular  a  nodulated 
tumour  results,  while  the  nipple  and  overlying  skin  become 
drawn  in.  The  axillary  glands  may  also  enlarge,  and  there 
may  be  watery  discharge  from  the  nipple.  Eventually  all  that 
remains  of  the  once  hypertrophied  organ  is  a  small,  hard, 
shrivelled  nodule,  which  is  often  much  smaller  than  the  healthy 
breast  (fig.  72). 

The  progress  of  the  disease  is  generally  irregular,  sta- 
tionary periods  alternating  with  periods  of  regression  and 
active  progress.  It  runs  a  chronic  course.  In  the  inflam- 
matory stage  there  is  great  increase  of  the  stroma,  which  is 
infiltrated  with  leucocytes,  and  its  nuclei  are  unduly  numerous. 
These  changes  are  most  marked  in  the  vicinity  of  the  glandu- 
lar structures.  As  the  disease  spreads  the  fatty  tissue  entirely 
disappears,  and  is  replaced  by  an  oedematous  fibroid  tissue. 
Parts  thus  affected  present  an  opaque,  whitish,  lardaceous 
aspect.  During  this  stage  the  epithelial  lining  of  the  glan- 
dular structures  proliferates,  and  the  cells  increase  in  number. 
Subsequently  they  atrophy  and  disintegrate.  As  the  contrac- 
tile stage  sets  in,  the  stromal  leucocytes  and  nuclei  diminish, 
and  they  are  replaced  by  rnarked  sclerosis,  especially  in  the 
vicinity  of  the  glandular  structures.  These  are  consequently 
irregularly  compressed  and  distorted.  Great  numbers  of  acini 
and  small  ducts  completely  disappear.  These  atrophic  changes 
often  coincide  with  a  certain  amount  of  glandular  ectasia. 
In  connection  with  the  latter,  and  with  the  remains  of  the 
pre-existing  glandular  structures,  numerous  small  cysts  some- 
times form.  When  this  cyst  formation  takes  place  in  the 
absence  of  marked  induration,  the  appearances  met  with  are 
indistinguishable  from  those  of  general  cystic  disease.  Indeed, 
it  is  not  improbable,  as  Delbet  has  ably  argued,  that  the  latter 
disease,  like  the  former,  is  also  the  outcome  of  chronic  inflam- 
mation.      Diffuse    chronic    mastitis    has    been    confounded    by 


532  INFLAMMATION    AND    SUPPURATION. 

some  pathologists  with  the  fibrous  form  of  hypertrophy ;  but 
in  reaHty  the  two  diseases  are  totally  distinct.  The  fibrous 
overgrowth  in  hypertrophy  is  progressive,  and  as  it  is  not  the 
outcome  of  inflammation,  there  is  no  subsequent  contractility. 

This  form  of  mastitis  is  commonest  at  about  the  climacteric, 
but  it  may  arise  at  any  period  from  puberty  upwards.  It  not 
unfrequently  originates  as  a  post-puerperal  sequela.  Generally 
only  one  breast  is  affected,  but  not  unfrequently  both — either 
simultaneously  or  consecutively,  usually  the  latter. 

In  most  cases  the  disease  eventually  terminates  in  resolution, 
the  gland  remaining  permanently  diminished  in  size.  Very 
exceptionally  the  diseased  part  may  calcify,  as  in  cases  by 
Bryk,  Berard,  and  others. 

I  have  found  belladonna  and  glycerine,  mixed  with  an  equal 
part  of  iodide  of  lead  or  compound  mercury  ointment,  spread  on 
lint,  a  very  effectual  application,  especially  when  combined  with 
compression  by  strapping,  &c..  or  by  a  special  compressor.^^ 
This  local  treatment  should  be  associated  with  the  internal 
administration  of  iodide  of  potassium.  When  persistent  painful 
swelling  remains  in  spite  of  treatment,  it  may  be  concluded 
that  cysts  are  present.  Under  these  circumstances,  especially 
if  there  are  indications  of  the  tumour  increasing  in  size,  the 
breast  should  be  removed  by  Thomas'  subcutaneous  method, 
leaving  the  skin,  nipple  and  areola  intact. 

As  an  example  of  the  cirrhosing  form  of  the  disease,  the 

following  case  by  Billroth^*^  is  of  interest.     Referring  to  it  he 

says :  "  I    was    inclined   to   doubt  the    existence  of  a   chronic 

mastitis,  ending  in  scirrhous  contraction,  until  I  met  with  this 

case." 

A  healthy-looking  peasant  woman,  aged  45,  the  mother  of  nine  children, 
the  last  of  whom  was  born  two  and  a-half  years  ago,  came  under  observa- 
tion with  her  left  breast  in  the  condition  represented  in  fig.  72.  In  the  place 
of  the  mamma  could  be  felt  a  hard,  irregularly  nodulated  swelling,  which 
was  adherent  to  the  overlying  skin,  but  not  to  the  subjacent  muscle.     The 


"    Viile  chnpler  xxv. 

'*  Deutsche  Ckir.,  Lief,  xli.,  S.  33. 


CHRONIC    MASTITIS.  '  533 

nipple  was  markedly  retracted  ;  and  so  was  the  overlying  adherent  skin, 
which  was  thrown  thereby  into  irregular  folds.  There  was  no  pain,  nor  had 
there  ever  been  any.  The  axillary  glands  were  not  obviously  affected.  The 
patient  said  she  had  been  accustomed  to  suckle  each  of  her  children  for  about 
sixteen  months.  She  had  never  had  any  previous  injury  or  disease  of  the 
breast.  About  two  years  ago,  when  suckling  her  last  child,  she  noticed  a 
hard  lump,  the  size  of  a  hazel-nut,  in  her  left  breast  above  the  nipple.  This 
slowly  but  steadily  increased,  and  gradually  the  whole  gland  became 
deformed.  Her  right  breast  was  perfectly  normal.  The  catamenia  still 
continued  regularly.     Billroth  advised  palliative  treatment. 

Labbe  and  Coyne^^  have  reported  a  somewhat  similar  case, 
in  which  the  atrophic  changes  had  not  yet  supervened. 

A  woman,  aged  40,  after  a  normal  accoucheinent  began  to  suckle  her 
child.  Having  done  so  for  two  or  three  months,  she  was  obliged  to  desist, 
because  of  the  supervention  of  pain  and  swelling  in  her  left  breast.  In 
the  course  of  the  next  year  the  breast  enlarged  considerably,  and  she 
occasionally  suffered  from  intermittent  febrile  attacks.  On  examination, 
at  the  end  of  this  time,  the  left  breast  was  twice  as  large  as  its  fellow  ;  the 
whole  gland  was  hard  and  bossy,  and  adherent  to  the  overlying  skin, 
which  was  thickened  and  in  the  condition  known  as  '"''peau  dorangeP 
The  subcutaneous  veins  were  greatly  enlarged  ;  but  there  was  no  obvious 
affection  of  the  axillary  glands.  The  diseased  part  was  extirpated ;  and 
the  wound  soon  healed.  On  examination  the  whole  breast  and  the 
overlying  skin  appeared  to  be  affected  with  chronic  inflammation  ;  the 
augmented  size  being  due  to  the  great  increase  in  the  fibrous  tissue.  In 
the  axillary  and  upper  part  of  the  affected  breast  there  was  an  encapsuled, 
puriform  collection,  the  size  of  an  almond.  Histological  examination  showed 
hyperplasia  of  the  stroma,  which  was  everywhere  infiltrated  with  numerous 
small  round  cells. 

Two  good  specimens  of  this  disease  are  to  be  found  in  the 

University   College  Museum  (Nos.    1 950-1    of  the   Pathological 

Series).     No.  1950  is  described  as  follows  in  the  catalogue  : — 

A  thin,  flattened  breast,  affected  with  general  chronic  mastitis.  There 
is  scarcely  any  fat  over  it.  Its  substance  presents  an  opaque  appearance 
intersected  with  dense,  fibroid  bands.  In  this  numerous  small  cysts  are 
embedded,  many  of  which  are  so  minute  as  to  be  only  just  visible  to  the 
naked  eye.  They  are  lined  by  a  smooth  membrane.  From  a  spinster,  aged 
40,  whose  right  breast  had  been  amputated,  for  what  she  calls  cancer— but 
which  was  probably  chronic  mastitis — some  time  previously.  Soon  after  this 
operation  her  left  breast  became  painful.  On  examination  the  left  breast 
was  obviously  unduly  enlarged,  tender,  indurated  and  bossy.  It  was  removed 
by  amputation. 


"  "  Traite  des  Tumeurs  Benignes  du  Sein,"  p.  243. 


534  INFLAMMATION    AND    SUPPURATION. 

In  the  Hiinterian  Museum  (No.  4819B  of  the  Pathological 
Series)  there  is  an  interesting  specimen  of  diffuse  chronic 
mastitis,  which  shows  the  atrophic  stage  of  the  disease  in  the 
breast  itself,  while  the  nipple  is  greatly  enlarged  from  more 
recent  inflammatory  hyperplasia. 

It  is  described  in  the  catalogue^^  as  an  extremely  atrophied  breast,  of 
which  the  nipple  is  greatly  enlarged  from  overgrowth  of  its  fibrous  tissue. 
Histological  examination  revealed  great  increase  of  mammillary  fibrous 
tissue  with  atrophic  ducts  ;  the  adjacent  parts  of  the  breast  were  similarly 
affected.  It  was  removed  by  Bryant  from  an  elderly  lady.  Cases  of  this 
kind  are  sometimes  erroneously  cited  as  examples  of  hypertrophy  of  the 
nipple. 

It  seems  to  me  certain  that  Bryk's^^  remarkable  case  of  cal- 
cified mamma  belongs  to  this  category.  At  any  rate  we  know 
that  chronically  inflamed  structures  are  more  prone  to  calcify 
than  healthy  ones,  and  the  history  of  this  case  points  to  previous 
rheumatic  inflammation. 

The  patient  was  a  childless,  married  woman,  aged  62,  who  had  all  her 
life  been  subject  to  rheumatism.  About  eleven  months  before  coming  under 
observation,  severe  pain  supervened  suddenly  in  her  left  breast,  which  she 
attributed  to  rheumatism,  and  a  tumour  subsequently  formed.  On  exami- 
nation, a  hard  tumour,  the  size  of  a  fowl's  ^%%^  was  felt  there.  The  breast 
was  amputated.  It  was  then  found  that  the  tumour  consisted  of  a  solid 
calcareous  mass,  surrounded  by  fibro-fatty  tissue.  The  calcification  had  in- 
vaded the  whole  of  the  mammary  stroma,  and  so  had  caused  atrophy  of  the 
parenchymatous  structures. 

I  have  met  with  an  instance  of  chronic  diffuse  mastitis  in  the 
male  breast.^"  Anderson,^^  Tuffler,^^  and  others  have  recorded 
similar  cases  ;  and  there  is  a  specimen  of  this  kind  in  the 
Ifniversity  College  Museum  (No.  1952  of  the  Pathological 
Series). 

Anderson's  patient  was  a  man,  aged  45,  with  enlargement  and  induration 
of  the  whole  of  the  breast,  of  six  months'  duration.  Histologically  there  was 
seen  great  increase  of  the  fibrous  tissue  in  which  a  few  glandular  elements 


'«  Vol.  iv.,  1885,  p.  477. 

'»  Arch.f.klin.  Chir.,  Bd.  xxv.,  1881,  S.  808. 

^^  Q.v.  ch.  xxi.,  §  iv. 

'-'   Trans.  Path.  Soc.  Lond.,  1893. 

"  Bull,  de  la  Soc.  Attat.,  1888,  p.  42. 


CHRONIC    MASTITIS.  535 

were  embedded,  and  in  their  vicinity  there  was  a  considerable  amount  of 
small  round-celled  infiltration. 

In  Tuffier's  case,  a  man,  aged  27,  presented  with  an  induration  of  his 
left  breast  of  six  months'  duration,  which  supervened  after  pleurisy.  The 
nipple  and  skin  were  intact,  but  the  axillary  glands  were  slightly  enlarged. 
The  breast  was  extirpated.  Histological  examination  after  removal  revealed 
chronic  mastitis. 

In  another  case  the  patient  was  a  vigorous  man,  aged  42,  who  after  a 
fall  five  months  ago,  first  noticed  swelling  of  his  right  breast.  On  examina- 
tion, the  whole  breast  felt  indurated,  bossy  and  finely  nodular,  forming  a 
hard  plaque  ^  cvxx.  in  diameter  and  2  cm.  thick.  The  overlying  skin  was 
unaffected  and  mobile.  The  diseased  part  was  extirpated.  Histologically 
examined  it  consisted  of  dense  fibrous  tissue  with  here  and  there  a  few 
glandular  structures  interspersed. 

A  curious  form  of  subacute  transitory  inflammation  of  the 
breast,  chiefly  affecting  men,  has  been  observed  by  Leudet,^^ 
Allot/*  and  others,  in  association  with  phthisis.  It  is  accom- 
panied by  pain  and  swelling.  Its  onset  appears  to  coincide 
with  the  development  of  tubercle  in  the  lung  of  the  correspond- 
ing side ;  but  according  to  Klippel,^^  the  affection  itself  is  not 
tubercular.  I  have  elsewhere*  recorded  an  example  of  a  similar 
affection  of  the  female  breast. 

B.  T\\&  periductal  form  of  chronic  mastitis  was  long  ago  recog- 
nised by  Velpeau,  Virchow  and  Billroth,  although  it  has  only 
recently  been  made  the  object  of  special  study.  Koenig^^  and 
Phocas^^  were  among  the  first  to  publish  a  satisfactory  account 
of  this  disease.  By  the  latter  it  was  designated  "  maladie 
noueuse ;"  and  Nordmann^^  has  lately  studied  the  same  condi- 
tion under  the  name  of  ^^ plexiform  fibroma"  The  disease  is 
essentially  a  peri-canalicular  chronic  inflammation,  limited  to 
the  vicinity  of  the  glandular  structures ;  and  as  the  inflamma- 
tory lesions  subside  they  are  followed  by  sclerosing  fibrosis.     In 


-^  Arch.  Gen.  de  Med.,  Jan.,  1886. 
-'   These  de  Paris,  1887. 
"^'^  Bull,  de  la  Soc.  Anat.,  1887,  p.  246. 
"  P.  342,  case  (2). 

=«  Ceni.f.  Chir.,  1893,  No.  3,  S.  49. 
^'   These  de  Paris,  1886. 

^  "  Ueber  das  plexifornie  Fibrome  der    Mamma,"  Arch.  f.  path.  Anat.,  Bd. 
cxxvii. ,  S.  338. 


536  INFLARBFATION    AND    SUPPURATION. 

a  breast  thus  affected,  multiple  hard  nodules,  freely  mobile, 
although  obviously  connected  with  the  mamma  itself,  can  be 
felt.  The  largest  of  these  seldom  exceeds  the  size  of  a  hazel- 
nut or  walnut,  and  sometimes  it  is  no  bigger  than  a  pea.  In 
addition  to  these,  on  careful  palpation,  there  can  often  be 
felt  throughout  the  gland,  an  immense  number  of  minute 
hard  bodies,  not  larger  than  pins'  heads.  The  tumours  are 
generally  tender  on  pressure ;  they  seldom  cause  mammillary 
retraction.  The  onset  is  insidious,  it  is  often  only  by  some 
accident  that  the  existence  of  the  disease  is  discovered,  as 
it  causes  but  little  deformity.  Sometimes  pain  or  tenderness 
is  the  revealing  symptom.  Usually  only  one  breast  is  affected, 
but  exceptionally  both.  The  axillary  glands  occasionally 
enlarge.  It  runs  a  chronic,  irregular,  oscillating  course.  Some 
nodules  diminish,  others  increase,  and  new  ones  form.  It  is 
commonest  in  middle-aged  women,  near  the  climacteric.  In 
some  cases  its  origin  is  post-puerperal ;  in  others  it  appears 
to  be  connected  with  catamenial  derangements ;  and  in  certain 
cases  it  has  been  attributed  to  local  injury.  The  disease  usually 
eventually  terminates  in  resolution. 

In  many  cases,  however,  periductal  sclerosis  persists ;  and 
Delbet^**  has  very  ably  argued,  that  general  cystic  disease 
often   originates   in   connection   with  these  residual  lesions. 

The  treatment  to  be  adopted  in  this  form  of  mastitis  is 
similar  to  that  for  the  diffuse  variety. 

C.  The  account  I  have  to  give  of  chronic  circumscribed 
mastitis  is  based  on  the  study  of  about  a  dozen  cases.  The 
disease  usually  presents  as  a  circumscribed  tumour  of  ovoid  or 
rounded  shape,  and  the  size  of  a  walnut.  Not  unfrequently, 
instead  of  a  rounded  tumour,  an  indurated  plaque  is  met  with. 
In  any  event  the  diseased  part  feels  hard,  and  finely  nodular, 
but  on  careful  palpation  less  circumscribed  than  it  at  first 
appeared.  The  tumour  is  found  to  be  intimately  blended  with 
the  gland.     There  is  usually  tenderness  on  pressure  and  some- 


Maladie  Kystique  et  Mammileclironique,"  Bull.  delaSoc.  ^/lal.,  }zn.,  1893. 


CHRONIC    MASTITIS,  537 

times  pain  is  complained  of.  The  mass,  as  a  rule,  is  freely 
mobile,  but  occasionally  the  overlying  skin  becomes  adherent. 
The  nipple  generally  remains  normal,  but  sometimes  it  is 
retracted.  Enlargement  of  the  axillary  glands  is  only  occa- 
sionally met  with.  Histologically  examined,  the  tumour  is 
seen  to  consist  of  a  few  glandular  structures — ducts  and  acini — 
embedded  in  a  relatively  excessive  amount  of  fibrous  stroma, 
presenting,  in  variable  degree,  the  usual  signs  of  chronic 
inflammation.  The  small  ducts  and  acini  are  often  more 
widely  separated  and  irregularly  arranged  than  in  the  normal 
state  ;  they  are  also  generally  unduly  large,  from  proliferation 
of  their  lining  cells,  and  sometimes  deliquescence  of  the  latter 
leads  to  the  formation  of  small  cysts.  It  occasionally  happens 
that  the  glandular  structures  are  destroyed  by  atrophy,  so  that 
they  almost  entirely  disappear  from  the  morbid  mass ;  but  this 
is  decidedly  rare.  Exceptionally,  more  than  a  single  tumour  is 
met  with  in  one  breast,  and  —  still  more  exceptionally  —  both 
may  be  affected.  Contrary  to  what  is  generally  stated,  I  have 
found  the  disease  to  be  as  common  in  single  as  in  married 
women.  In  the  latter  it  generally  originates  as  a  post-puerperal 
affection  ;  in  the  former,  a  blow  or  injury  is  usually  assigned  as 
its  cause.  Indurations  of  this  kind  sometimes  undoubtedly  arise 
from  the  pressure  of  the  corset.  Foreign  bodies  embedded  in 
the  breast  (pins,  needles,  bits  of  glass,  &c.)  are  also  exceptional 
causes.  Of  fourteen  patients  on  my  list,  the  oldest  was  66  at 
the  onset  of  the  disease,  and  the  youngest  i6 ;  but  most  cases 
originated  between  35  and  50.  A  small  lump  in  the  breast  is 
generally  the  first  thing  noticed,  and  this  is  occasionally  painful 
or  tender.  Its  increase  is  slow,  so  that  in  the  absence  of  pain, 
a  surgeon  is  seldom  consulted  until  it  has  existed  for  one  or 
more  years.  It  is  sometimes  exceedingly  difficult  to  diagnose 
tumours  of  this  kind  from  hard  cancer.  For  an  account  of  a 
typical  case  of  this  kind,  and  for  some  remarks  on  the  differ- 
ential diagnosis,  I  must  refer  the  reader  to  a  previous  chapter.* 

*  Ch.    xii.,  p.   341. 


53o  INFLAMMATION    AND    SUPPURATION. 

A  considerable  proportion  of  these  cases,  especially  when 
properly  treated,  eventually  terminate  in  resolution.  Velpeau^^ 
has  recorded  several  instances  of  this,  of  which  the  following  is 
a  good  example  : — 

A  short,  stout,  married  lady,  aged  48,  one  year  ago  first  noticed  a  lump 
in  her  breast.  On  examination  there  was  found,  in  the  lower  and  outer  part 
of  her  right  breast,  a  hard  tumour  the  size  of  a  fowl's  egg.  It  was  intimately 
blended  with  the  surrounding  structures,  and  its  margins  were  ill  defined. 
The  overlying  skin  was  adherent,  depressed  and  indurated.  It  was  painful, 
and  had  been  so  for  the  last  few  months.  Her  general  health  was  good, 
and  menstruation  still  continued.  She  was  treated  with  iodide  of  potassium 
internally,  and  the  inunction  of  iodide  of  lead  ointment  into  the  breast.  The 
tumour  soon  afterwards  began  to  decrease  ;  in  a  few  months'  time  it  was 
markedly  smaller.  At  the  end  of  eight  months  it  had  quite  disappeared. 
When  last  seen,  ten  years  later,  the  breast  was  quite  normal. 

In  others  after  a  time  chronic  abscess  supervenes.  In  yet 
others,  the  indurated  nodule  persists  indefinitely.  Influenced 
by  the  prevalent  desire  to  extend  the  microbe  theory,  Delbet 
and  others  have  argued,  that  the  ordinary  fibro-adenomata  are 
eventually  evolved  out  of  these  chronic  inflammatory  indura- 
tions. This  seems  to  me  to  be  a  purely  gratuitous  assumption. 
Very  exceptionally  tumours  of  this  kind  calcify,  as  appears  to 
have  happened  in  the  following  remarkable  case  by  Heudoupe.^^ 

A  woman,  aged  35,  with  great  inflammatory  swelling  of  her  left  breast, 
over  the  upper  part  of  which  was  a  large  irregularly  ulcerated  cavity,  whence 
pus  freely  escaped  ;  at  the  bottom  of  this,  with  a  probe,  a  hard,  porous 
mass  was  felt.  Under  ether  spray,  a  calcareous  mass,  the  size  of  a  fowl's 
egg,  was  extracted  from  the  abscess  cavity  in  which  it  lay.  The  antecedent 
history  was  as  follows  : — Twenty  years  ago  she  hurt  her  breast  by  a  fall. 
Soon  afterwards  a  lump — the  size  of  a  nut — formed  at  the  seat  of  injury. 
She  married,  and  had  two  children,  whom  she  suckled.  Four  years  ago, 
after  another  injury,  an  abscess  formed  in  connection  with  the  old  lump  ; 
it  was  incised,  and  a  pus-discharging  fistula  subsequently  remained,  in  con- 
nection with  which  the  present  ulceration,  &c.,  had  since  developed. 

I  have  seen  several  instances  in  which  the  breast  has  been 
amputated  for  chronic  inflammatory  indurations  mistaken  for 
cancer,  one  of  which  has  been  previously  related.* 

^  "  Traite  des  Maladies  du  Sein,"  &c.,  p.  582. 

^'  Gaz.  des  NSp.,  25  aout,  1887,  p.  841.  "  Obs.  de  tumeur  calcaire  de  la 
mamelle." 

*  Ch.  xii.,  §  ii.,  p.   341. 


COLD    ABSCESS.  539 

There    is  a  specimen    of  this    kind    in    University    College 

Museum  (No.  1952  of  the  Pathological  Series).     It  is  described 

as  follows  in  the  catalogue  :^^ — 

Breast  extirpated  for  cancer,  containing  a  hard  tumour  three-quarters  of 
an  inch  in  diameter,  which  was  situated  immediately  beneath  the  skin,  to 
which  it  slightly  adhered.  The  tumour  occupied  the  peripheral  part  of  the 
gland  near  the  axilla.  Its  limits  were  well  defined.  The  adjacent  lymph 
glands  were  slightly  enlarged  and  hard.  On  examination  after  removal  the 
tumour  looked  like  an  indurated  segment  of  the  gland.  Histologically  it 
consisted  of  dense  fibrous  tissue,  containing  a  few  glandular  structures,  in 
connection  with  which  some  small  cysts  had  developed. 

In  the  treatment  of  this  disease  compression  and  the 
remedies  recommended  for  the  other  forms  of  chronic  mastitis 
should  first  be  tried.  These  failing,  if  the  patient  experience 
any  annoyance  from  the  persistent  induration,  it  should  be 
excised,  the  wound  being  closed  by  deep  and  superficial  sutures, 
so  as  to  secure  immediate  union ;  or  the  tumour  may  be 
removed  by  Thomas'  method. 

In  the  male  breast  similar  lesions  are  occasionally  met  with 

of  which  the  following  is  an  example  -F" — 

A  man,  aged  27,  eight  months  ago  first  noticed  a  lump  in  his  right 
breast  below  the  nipple.  It  increased  slowly  and  became  rather  tender. 
On  examination  a  lobulated,  semi-lunar,  indurated  mass  could  be  felt  at  the 
lower  part  of  the  breast.  The  adjacent  axillary  glands  were  enlarged.  The 
left  breast  was  sound.  The  diseased  breast  was  excised,  the  nipple  being  left. 
On  histological  examination  of  the  indurated  area,  the  ordinary  signs  of 
chronic  mastitis  were  found — great  increase  of  the  inter-acinous  fibrous  tissue, 
and  infiltration  of  the  stroma  with  small  round  cells,  which  were  especially 
numerous  in  the  immediate  vicinity  of  the  glandular  structures. 

For  further  information  on  this  subject,  reference  may  be 

made  to  the  thesis  of  Moizard.^* 

&    III. Cold  Abscess. 

Great  interest  attaches  to  cold  abscess  of  the  breast,  not 
only  per  se,  but  also  because  of  the  aetiological  connection  with 

^2  "Path.  Catalogue,"  part  ii.,  1887,  p.  439. 
^  Umv.  Coll.  Hasp.  Rep.,  1881,  p.  40. 

^*  "  Contrib.  a  I'etude  de  la  Mammite  chez  rHomme,"  These  de  Paris,  No.  414, 
1881. 


540  INFLAMMATION    AND    SUPPURATION. 

tubercle,  and  the  close  clinical  resemblance  of  many  cases  to 
cancer  and  other  neoplasms.  Only  a  few  years  ago,  surgeons 
never  thought  of  associating  cold  abscesses  with  tubercle ; 
lately,  however,  many  cases  have  been  proved  to  be  due  to  this 
cause,  and  now  we  have  pathologists  who  assert  that  all  cold 
abscesses  are  of  tubercular  origin.  The  truth  seems  to  lie 
between  these  extremes,  for  many  cold  abscesses  in  the  breast 
undoubtedly  occur  independently  of  tubercle.  These  I  now 
propose  to  describe,  leaving  the  tubercular  ones  for  subsequent 
discussion.  My  remarks  will  be  based  chiefly  on  the  study  of 
twenty-five  cases. 

The  immense  majority  of  simple  chronic  abscesses  are  intra- 
glandular,  that  is  to  say,  they  originate  in  the  corpus  mainiiKB ; 
thus  of  twenty-two  cases  the  abscess  was  centrally  situated 
in  sixteen,  and  peripheral  only  in  six.  Of  the  latter  four  were 
in  the  axillary  segment  and  two  in  the  upper.  It  is  only  very 
rarely  that  chronic  abscesses  originate  in  the  subcutaneous  or 
retro-mammary  tissues.  Cold  abscesses  have  occasionally  been 
met  with  in  the  mammary  region  or  its  vicinity,  which  have 
originated,  not  from  the  breast  itself,  but  from  adjacent  parts, 
such  as  the  ribs,  sternum,  or  even  the  intra-thoracic  structures. 

With  regard  to  the  influence  of  sex,  only  three  of  the  twenty- 
five  cases  in  my  list  were  males.  The  affected  breast  usually 
contains  only  a  single  abscess  ;  this  was  the  condition  in  twenty 
out  of  twenty-two  cases.  In  two  of  these  instances  a  fistula  had 
formed  from  bursting  of  the  abscess.  Both  breasts  are  equally 
liable;  but  in  no  instance  was  more  than  a  single  one  affected. 
In  several  cases,  in  addition  to  the  abscess  tumour,  the  whole 
breast  was  indurated  and  sclerosed  from  diffuse  mastitis.  Most 
of  the  patients  were  married  women,  but  many  single  ones 
were  also  affected — the  proportion  being  fifteen  married  to  six 
single.  Of  the  married,  in  only  eight  cases  was  the  super- 
vention of  the  disease  associated  with  pregnancy  or  lactation. 
The  history  of  most  of  these  cases  justifies  the  belief  that  they 
were  of  galactocele  origin.  Only  three  were  associated  with 
previous  injur)'  or  disease  of  the  breast — sore  nipples  2,  blow  i. 


COLD    ABSCESS.  54  I 

The    following    is    a    typical     instance^^    of    abscess    thus 

originating  : — 

A  married  woman,  aged  34,  the  mother  of  two  children,  one  month  after 
the  birth  of  her  last  child  eighteen  months  ago — while  still  suckling — first 
noticed  at  the  upper  part  of  the  axillary  border  of  her  right  breast  a  hard 
lump.  When  she  came  under  treatment  there  was  in  this  situation  a 
nodule,  the  size  of  a  marble,  of  firm,  elastic  consistency,  to  which  the 
overlying  skin  was  slightly  adherent.  The  axillary  glands  were  normal — as 
also  was  the  nipple.  The  tumour  was  dissected  out.  It  contained  puriform 
substance  of  cream  cheese  appearance.  There  was  no  family  history  of 
tubercle. 

In   but  very  few  of  these  cases  does  suppuration  appear  to 

have  supervened  on  chronic  mastitis,  as  in  the  following  case.-"^ 

A  man,  aged  47,  two  years  ago  first  noticed  some  enlargement  of  his 
breast,  which  after  a  time  diminished.  Five  weeks  ago  the  breast  increased 
in  size  and  became  painful.  It  was  then  incised,  and  half  an  ounce  of  pus 
was  evacuated.  When  he  came  under  observation  a  hard  swelling  occupied 
the  centre  of  the  breast,  extending  for  about  three-quarters  of  an  inch  beyond 
the  areola,  in  all  directions.  The  overlying  skin  was  mobile,  and  the  swell- 
ing itself  had  no  adhesion  with  the  subjacent  structures.  There  were  no  en- 
larged glands  in  the  axilla.  An  exploratory  incision  was  made  into  the 
tumour,  which,  proving  to  be  of  inflammatory  nature,  was  excised.  He  was 
convalescent  a  fortnight  later. 

Of  the  seven  married  women  in  whom  the  disease  originated 
independently  of  lactation,  in  two  it  was  attributed  to  a  blow, 
and  in  two  to  sore  and  retracted  nipple.  Of  the  six  cases  in 
unmarried  women,  in  one  the  disease  followed  a  blow,  and  in 
one  it  was  associated  with  a  congenitally  retracted  nipple. 
Thus  in  most  cases  there  was  no  obvious  cause  for  it. 

Generally  its  duration  had  been  so  comparatively  short,  as 
hardly  to  warrant  the  application  of  the  term  "chronic;"  for 
in  half  the  total  cases  it  had  lasted  under  six  months,  and  in 
only  five  did  it  exceed  one  year,  the  longest  term  being  twelve 
years. 

The  disease  usually  presented  as  a  firm,  nodular  tumour, 
situated  in  the  middle  of  the  breast,  varying  in  size  from  a 
hazel-nut  to  a  cocoa-nut,  the  average  size  being  between  that  of 
a  walnut  and  Tangerine  orange.     Retraction  of  the  nipple  was 

«  Univ.  Coll.  Hosp.  Rep.,  1889,  p.  98. 
="=  Ilnd.,  1S85,  p.  74. 


542  INFLAMMATION    AND    SUPPURATION. 

the  symptom  most  frequently  met  with,  for  this  occurred  in 
thirteen  out  of  twenty-two  cases.  In  eight  cases  the  overlying 
skin  was  adherent ;  in  six  there  was  some  pain  or  tenderness ; 
in  five  the  axillary  glands  were  enlarged  ;  in  five  there  was  an 
indistinct  sense  of  fluctuation  ;  and  in  two  puriform  discharge 
from  the  nipple. 

Some  idea  of  the  difficulty  of  diagnosing  such  cases  from 
cancer,  may  be  inferred  from  the  fact  that  in  five  of  my  twenty- 
two  cases,  the  breast  had  been  amputated  for  cancer,  and  it  was 
only  afterwards  that  its  real  nature  was  discovered. 

Of  this  the  following  is  a  typical  example  ■}'^ — 

A  pale,  but  well-nourished  and  otherwise  healthy-looking  spinster,  aged 
32,  three  years  ago  first  noticed  a  painful  swelling  in  her  breast.  It  formed 
without  any  injury  or  other  known  cause.  There  was  family  history  of 
tubercle.  On  examination,  in  the  middle  of  the  left  breast  there  was  found  a 
hard  mass,  about  two  inches  in  diameter,  not  distinctly  separable  from  the 
surrounding  parts.  The  overlying  skin  was  reddened  and  adherent,  and  the 
nipple  was  retracted.  There  was  no  fluctuation ;  but  the  tumour  was 
painful  and  tender.  The  axillary  glands  were  normal.  Under  these  cir- 
cumstances cancer  was  diagnosed,  and  the  breast  amputated.  On  exami- 
nation of  the  part  after  removal,  in  the  midst  of  the  sclerosed  breast  there 
was  found  a  small  abscess  cavity,  about  half  an  inch  in  diameter,  lined  with 
a  thin  layer  of  pinkish  granulations,  and  outside  this  there  was  a  thick 
layer  of  sclerosed  tissue. 

For  the  treatment  of  these  cases  it  usually  suffices  to  lay 

open  the  abscess  cavity,  scrape  it  with  a  Volkmann's  scoop,  and 

having  washed  it  out  with  antiseptic  solution,  close  it  with  deep 

and  superficial  sutures.       When    there   is   much    sclerosis,  the 

diseased  part  should  be  dissected  out. 

S     IV. Inflammatory  Diseases  of  the  Nipple,  Areola,  &c. 

As  the  result  of  congenital  developmental  defects,  the 
nipples  are  frequently  short,  stunted,  depressed,  invaginated  or 
otherwise  imperfectly  formed.*     Defects  of  this  kind  predispose 

"  No.   1953  in  the  Path.  Series,  Univ.   Coll.   Museum  :  for  a  similar  case  vide 

P-  342. 

*  For  an  estimate  of  its  frequency,  vide  p.  338.  DIuski  reports  that  of  433  recently 
confined  women  in  Baudclocque's  clinic,  181  had  sore  nipples,  99  of  the  cases  l)eing 
slight.  One  hundred  and  eighteen  of  them  had  malformed  nipples.  Those  who 
suckled  were  less  afifected  than  those  who  did  not,  in  the  proportion  of  32  to  40  per 
cent.  (T/iifse  de  Paris,  1894,  "  Contrib.  a  I'clude  de  I'allaitment  maternel  "). 


INFLAMMATORY    DISEASES    OF    THE    NIPPLE,    ETC.       543 

them  to  inflammatory  and  other  affections  during  lactation. 
On  the  other  hand,  inflammatory  lesions  and  irritative  states 
of  the  part,  often  cause  retraction  of  the  nipple,  by  inducing 
spasm  of  its  longitudinal  muscle  bands.  When  the  extreme 
delicacy  of  the  skin  of  the  nipple,  its  intimate  adhesion  with 
the  subjacent  parts,  its  numerous  folds  and  glands,  are  borne  in 
mind,  we  need  not  be  surprised,  that  at  the  commencement  of 
lactation,  even  in  women  with  well-formed  nipples,  inflamma- 
tion is  so  common.  Unhealthy  conditions  of  the  child's  mouth, 
especially  such  as  are  associated  with  aphtha  and  other  forms  of 
stomatitis,  are  very  apt  to  cause  it.  Probably  abnormal  states 
of  the  mother's  milk  also  act  injuriously.  Certain  it  is  that 
undue  moistening  of  the  part  with  irritant  fluids  such  as  these, 
leading  to  maceration  and  exfoHation  of  the  epidermis,  is  usually 
the  chief  determining  factor.  Under  these  circumstances,  the 
nipple  becomes  red,  swollen,  and  tender.  Unless  properly  treated, 
erosions,  ulcers,  and  fissures  soon  form,  and  the  part  becomes 
exquisitely  tender.  Lesions  of  this  sort  are  commonest  at  the 
base  of  the  nipple,  where  it  joins  the  areola,  and  at  the  mam- 
millary  apex.*  When  disturbed  they  are  apt  to  bleed.  Several 
usually  exist.  They  generally  form  before  the  fifth  day.  Such 
conditions  hardly  ever  arise,  except  in  connection  with  preg- 
nancy and  lactation.  They  often  excite  an  amount  of  pain, 
constitutional  disturbance  and  mental  distress,  out  of  all  pro- 
portion to  their  size.  As  a  consequence  of  these  lesions,  small 
abscesses — which  are  often  multiple — occasionally  form  in  the 
areola,  or  even  in  the  nipple  itself  The  relation  of  the  fore- 
going conditions  to  acute  inflammatory  diseases  of  the  gland 
itself,  will  be  discussed  in  the  sequel. 

Pregnant  women  having  defectively  developed  or  retracted 
nipples,  should  endeavour  to  remedy  these  defects  by  appro- 
priate treatment  for  some  months  before  their  accoucheuieyit. 
In  slight  cases  the  daily  drawing  out  of  the  nipple,  aided  by 
friction  and  compression  of  its  base,  together  with  the  applica- 

*  According  to  Dluski,  the  seats  of  the  sores  in  his  181  cases  were  :— the  summit 
of  the  nipple  in  123,  its  base  in  54,  and  the  areola  alone  in  4  {op.  cit.). 


544  INFLAMMATION    AND    SUPrURATION. 

tion  of  lotions  for  hardening  the  epidermis,  such  as  aqueous 
solutions  of  brandy,  eaii  de  Cologne,  boric  acid  with  borax,  or 
boro-glyceride,  will  suffice.  There  can  be  no  doubt  but  that 
repeated  mechanical  irritation  of  the  nipple,  by  bringing  into 
action  its  muscle  fibres,  tends  to  cause  its  enlargement.  Nothing 
is  more  effective  in  this  respect  than  suction  by  the  mouth  of 
a  vigorous  child  or  of  another  woman.  In  default  of  buccal 
suction  the  ordinary  breast  reliever ^^  (fig.  73)  may  be  used;  or 
resort  may  be  had  to  the  old-fashioned  method  of  applying 
over  the  nipple  an  inverted  soda  water  bottle,  just  emptied  of 
hot  water.     In    connection  with   these   means   the   application 


Fig.  73. — Breast  reliever. 

of  thick  defensive  plaster,  having  an  aperture  in  the  centre  cor- 
responding to  the  nipple,  for  some  months  before  labour,  has 
proved  of  great  service.  The  plaster  used  should  be  about 
three  inches  in  diameter  and  half  an  inch  thick. 

When  these  methods  fail,  the  invaginated  nipple  may  be 
improved  by  the  operation  of  mammilla-plasty.  A  circular 
strip  of  skin,  together  with  the  subjacent  fibro-fatty  tissue,  is 
excised  from  the  prominent  cutaneous  fold  surrounding  the 
depressed  nipple ;  or  instead  of  a  circular  strip  two  crescentic 
pieces  may  be  removed  (Kchrer).  Care  should  be  taken  to  avoid 
injuring  the  subjacent  ducts;  this  will  be  rendered  almost  im- 
possible by  keeping  the  incisions  external  to  the  areola.  On 
suturing  together  the  opposite  cut  edges  of  the  mam  miliary 


*■*  As  supplied  by  Maw,  Son  and  Thompson,  of  London. 


INFLAMMATORY    DISEASES    OF    THE    NIPPLE,    ETC.       545 

and  mammary  skin,  the  nipple  will  be  pulled  up  into  its  proper 
position.  In  a  case  reported  by  Herman"''  the  operation  re- 
sulted in  a  permanent  cure.  Of  course  not  much  good  can  be 
expected  from  this  proceeding  when  the  nipple  is  congenitally 
stunted  and  malformed. 

When  the  time  for  suckling  comes  attention  should  be 
directed  to  the  mother's  nipples,  and  to  the  child's  mouth.  The 
nipples  should  be  kept  as  dry  as  possible,  and  free  from  putre- 
scent fluid.  To  effect  this,  suckling  should  be  regulated  to 
set  hours  ;  and  the  nipples  should  afterwards  be  bathed  with 
I  in  20  carbolic  acid  solution,  wiped  dry,  and  anointed  with 
boric  acid  ointment,  or  dusted  with  a  powder  consisting  of 
equal  parts  of  calamine  and  camphorated  chalk.  When  there 
is  a  constant  flow  of  milk,  protective  glass  receivers  should 
be  used,  in  which  the  overflow  collects.  To  keep  the  child's 
mouth  sweet  it  should  be  given  inel  boracis  to  suck,  with  which 
a  little  boric  acid  in  vaseline  has  been  mixed. 

If  the  nipples  have  become  sore  and  inflamed,  an  artifi- 
cial nipple  should  be  provided.  A  good  form  con- 
sists of  a  glass  shield  with  an  india-rubber  teat  for 
the  child  to  suck,  fixed  to  its  summit^"  (fig  74).  It 
should  be  washed  before  and  after  use  with  carbolic 
lotion.  Deep  fissures,  8z:c.,  should  be  lightly  cau- 
FiG.  74.      terised  with  a  fine,  pointed  pencil  of  nitrate  of  silver. 

An  artificial    ,,.,,.  ,  .  ,  ... 

nipple.  When  there  is  so  much  pam  and  constitutional 
weakness  that  suckling  cannot  be  continued,  means  must 
be  taken  to  relieve  the  breast  of  milk  and  to  arrest  its  further 
secretion  ;  while  at  the  same  time  the  enlarged  organ  should 
be  properly  supported. 

With  regard  to  eczej7tatoiis  affections  of  the  nipple  and  areola,** 
but  little  need  be  added  to  the  account  given  of  them  when 
treating  of  cancer  of  the  mammary  integument  (ch.  xv.).    Morbid 
conditions  of  this  kind  sometimes  affect  both  breasts,  and  not 


^^  Lancet,  vol.  ii.,  1889,  p.  12. 

'"'  As  supplied  by  Maw,  Son  and  Thompson,  of  London. 


546  INFLAMMATION    AND    SUPPURATION. 

only  the  nipple  and  areola,  but  also  the  adjacent  integument 
may  be  invaded.  These  lesions  frequently  arise  quite  inde- 
pendently of  lactation  and  pregnancy.  Eczematous  disease  of 
the  areola  and  nipple  is  rarely  associated  with  similar  disease 
in  other  parts  of  the  body.  Sometimes  after  a  time  it  is 
followed  by  chronic  mastitis,  or  abscess  of  the  breast.  In  this 
connection  Stumpf's"*^  observations  are  of  interest.  He  has 
demonstrated  the  presence  in  this  disease  of  a  staphylococcus, 
morphologically  identical  with  staphylococcus  pyogenes  aureus. 
The  same  microbe  he  found  also  in  the  milk  of  those  affected. 
He  considers  that  this  accounts  for  the  rebelliousness  of  the 
disease,  re-infection  constantly  taking  place  from  the  infected 
milk.  It  is  generally  a  very  chronic  affection,  and  difficult  to 
cure.  As  local  applications,  boric  acid  or  salicylic  acid  oint- 
ment may  be  used,  or  the  ung.  glycerini  plumbi  subacetatis. 
Velpeau  succeeded  in  curing  many  cases  with  white  precipitate 
ointment 

A  pruriginous  eruption  of  the  breasts,  associated  with  similar 
disease  elsewhere,  is  generally  due  to  scabies,  of  which  the 
breast  is  a  favourite  seat.  It  requires  to  be  treated  in  the  usual 
way  with  ung.  sulphuris,  &c. 

Herpes  zoster  of  the  mammary  region  is  occasionally  seen. 

^    V . Acute  Inflammation  and  Suppuration. 

Acute  inflammatory  diseases  of  the  breast  rarely  supervene 
except  at  periods  of  physiological  excitement,  when  there  is 
naturally  considerable  local  congestion.  Hence  it  is  chiefly  in 
the  newly  born,  at  puberty,  and  during  the  puerperal  state,  that 
these  affections  arise. 

(i)  In  the  newly  born  of  both  sexes,  as  previously  mentioned, 
considerable  formative  activity  takes  place  in  the  breasts,  with 
which  there  is  generally  associated  true  lacteal  secretion.  These 
changes  attain  their  maximum  between  the  eighth  and  fifteenth 
days.     At  this  period  acute  inflammation,  followed  by  suppura- 


*'  Mutuhener  7ned,  Wochenschr.,  No.  25,  1888. 


ACUTE    INFLAMMATION    AND    SUPPURATION.  547 

tion,  is  apt  to  supervene,  just  as  in  puerperal  women.  Some 
instances  of  this  kind  may  be  traced  to  improper  manipulation 
of  the  part  by  the  nurse,  with  the  object  of  "  breaking  the  nipple 
strings,"  or  of  "  rubbing  away  the  milk,"  in  accordance  with  a 
pernicious  old  custom.  The  local  application  of  belladonna  and 
hot  fomentations  suffices  for  the  cure  of  most  cases.  Care 
should  be  taken  to  recognise  the  supervention  of  suppuration  at 
an  early  date,  for  once  pus  has  formed  the  sooner  it  is  evacuated 
the  better.  Left  to  itself  suppuration  may  result  in  complete 
destruction  of  the  rudimentary  gland,  even  the  nipple  and 
areola  sloughing  away ;  or  the  gland  may  be  thereby  otherwise 
permanently  injured. 

(2)  The  physiological  congestion,  associated  with  the  de- 
velopment of  the  breasts  at  puberty,  occasionally  passes  on 
to  inflammation,  and  quite  exceptionally  the  latter  ends  in 
suppuration.  Even  in  male  subjects  similar  conditions  are 
occasionally  met  with.  The  treatment  is  the  same  as  for  the 
very  similar  affections  in  the  newly  born. 

(3)  The  great  majority  of  acute  inflammatory  diseases  of  the 
breast  arise  during  the  puerperal  state,  nearly  all  of  them  being 
associated  with  lactation.  WinckeP  estimated  that  after  i,oco 
consecutive  accouchements  up  to  1878,  mastitis  developed  in 
6  per  cent.  Deiss'*^  has  since  found  that  after  1,600  consecutive 
accouchements  up  to  1889,  only  ^-^  per  cent,  subsequently  de- 
veloped mastitis.  This  improved  result  is  probably  chiefly  due 
to  the  greater  attention  paid  to  hygienic  matters,  and  to  the 
routine  employment  of  antiseptics. 

These  diseases -are  of  most  frequent  occurrence  in  primiparse, 
and  there  is  a  consensus  of  opinion,  that  those  who  suckle,  are 
more  liable  than  those  who  do  not ;  but  the  most  liable  are  those 
who,  having  suckled  for  a  time,  then  suddenly  give  it  up.  Both 
breasts  are  not  unfrequently  affected.  Inflammation  usually 
begins  at  some  time  during  the  first  four  weeks  after  accoucJiemeiit, 


'-    Vide  p.  297. 

*^  "Inaug.  Diss.,"  Heidelberg,  18S9. 


548  INFLAMMATION    AND    SUPPURATION. 

most  cases  arising  at  from  about  the  eighth  to  the  tenth  days. 
It  rarely  originates  after  the  third  month,  except  at  quite  the 
end  of  lactation,  when  a  considerable  number  of  cases  arise, 
especially  in  those  who  have  unduly  prolonged  the  process. 

The  pathogeny  of  puerperal  mastitis  has  long  been  a  debate- 
able  subject ;  and  it  is  still  under  discussion.  As  previously 
mentioned,  it  is  conceivable  that  pathogenic  microbes  may  enter 
the  breast  either  by  the  blood  vessels,  the  lymphatics,  or  the 
ducts.  With  regard  to  infection  by  the  blood  vessels,  beyond 
the  fact  that  it  does  occur,  little  else  is  known  of  it.  As  to  the 
respective  parts  played  by  the  lymphatics  and  ducts  it  is  not 
easy  to  decide.  It  seems  certain,  however,  that  each  has  its  role. 
In  superficial  inflammations  of  the  breast,  especially  those  of 
erysipelatous  origin,  most  pathologists  are  agreed  that  the 
lymphatics  are  chiefly  concerned  in  the  spread  of  the  disease. 
In  other  cases  it  seems  probable  that  infection  takes  place  chiefly 
by  the  ducts.  It  was  formerly  very  generally  believed  that  over- 
distension of  the  ducts  with  milk,  and  coincident  stasis,  were  the 
chief  factors  concerned  in  determining  puerperal  mastitis.  It  is 
incontestable  that  such  lacteal  engorgement  actually  does  occur, 
and  it  is  generally  admitted  to  be  a  potent  predisposing  cause ; 
but  in  the  absence  of  pathogenic  microbes,  it  has  been  proved, 
as  previously  mentioned,  that  these  conditions  are  of  them- 
selves insufficient  to  produce  the  disease.  It  is  doubtlessly 
owing  to  the  production  of  mechanical  impediments  of  this 
kind,  that  mammillary  imperfections  are  so  frequently  asso- 
ciated with  puerperal  mastitis.  Of  97  patients  thus  affected, 
Birkett^*  found  that  no  less  than  48  were  associated  with  im- 
perfectly developed  nipples.  In  favour  of  the  canalicular  origin 
of  most  puerperal  abscesses,  it  may  be  mentioned,  that  on  press- 
ing them  pus  and  milk  may  often  be  made  to  exude  from  the 
nipple ;  and  after  incision  the  same  combination  may  be  seen  in 
the  discharge.  Of  Birkett's  97  cases  of  puerperal  mastitis,  in  19 
the  disease  was  associated  with  fissures  or  erosions  of  the  nipple, 

*'  Holmes'  "Syst.  of  Surgery,"  vol.  iii.,  1883,  p.  435. 


ACUTE    INFLAMMATION    AND    SUPPURATION.  549 

&c.  Pathologists  who  maintain  the  lymphatic  origin  of  most 
puerperal  abscesses  have  dwelt  much  on  this.  Probably  these 
lesions  act  injuriously  in  most  cases,  rather  by  preventing  suck- 
ling and  so  favouring  lacteal  engorgement  and  stasis,  than  as 
sources  of  lymphatic  injection. 

After  accouchement  \hQ.  breasts  naturally  become  considerably 
enlarged,  tender  and  reddish,  in  connection  with  the  establishment 
of  lactation  and  its  concomitant  congestion.  This  physiological 
fulness,  which  is  attended  with  some  constitutional  excitement 
and  uneasiness,  generally  attains  its  maximum  about  the  fourth 
day.  The  term  "  milk  fever "  was  formerly  applied  to  these 
phenomena.  Recent  investigations  have,  however,  demonstrated 
the  complete  absence  of  fever.  Hence,  when  under  these  cir- 
cumstances febrile  symptoms  arise,  their  presence  must  be  taken 
to  indicate  the  supervention  of  some  complication,  either  in 
connection  with  the  mammae  or  the  genital  tract.  In  patients 
with  large,  lax  mammae  the  tendency  to  congestion  is  often 
aggravated  by  their  dependent  position.  Here  relief  may  be 
afforded  by  raising  and  supporting  the  enlarged  organs.  In 
this  congested  state  comparatively  trivial  injuries  often  suffice 
to  determine  inflammation. 

A  sense  of  chilliness,  with  lobular  induration,  elevation  of 
temperature,  and  increase  of  the  congestive  symptoms  are 
usually  the  earliest  indications  of  its  supervention.  As  the 
induration  increases  tenderness  and  pain  develop.  At  first  the 
skin  over  the  affected  area  is  not  markedly  altered ;  but  as  the 
disease  progresses  it  becomes  red,  adherent,  and  even  cedematous. 
By  appropriate  treatment,  begun  early,  inflammation  may  be 
arrested,  and  the  disease  may  terminate  in  resolution.  More 
commonly,  however,  the  inflammation  spreads  and  suppuration 
supervenes.  This  is  accompanied  by  much  pain  and  constitu- 
tional disturbance,  only  to  be  relieved  by  evacuation  of  the  pus. 
Left  to  itself  this  generally  takes  about  a  fortnight,  but  when  the 
suppurative  focus  is  deeply  seated  it  may  take  longer.  Abscesses 
of  this  kind  are  frequently  multiple.  Sometimes,  as  soon  as  one 
has  been  evacuated  another  forms,  and  so  on  continuously  for 


550  INFLAMMATION    AND    SUPPURATION, 

months.  Velpeau*^  mentions  a  case  in  which  forty-six  abscesses 
formed  successively  in  one  breast  in  the  course  of  two  or  three 
months.  Thus  the  breast  may  become  riddled  with  sinuses. 
This  form  of  suppuration  is  attended  with  great  debility. 

It  is  usual  to  classify  mammary  abscesses  according  to  the 
situations  in  which  they  develop,  either  as  supra-mammary, 
intra-mammary,  or  infra-mammary.  In  the  siiperficial  varieties 
the  pus  points  quickly,  the  disease  runs  a  rapid  course,  and 
the  concomitant  constitutional  symptoms  are  seldom  severe. 
In  intra-glandular  suppuration  the  pus  collects  within  the 
corpus  viavimce.  Owing  to  the  unyielding  nature  of  the  sur- 
rounding structures  the  progress  of  the  disease  is  slow,  and  it  is 
attended  by  great  pain  and  severe  constitutional  disturbance, 
with  occasional  mental  aberration.  Siib-inammary  abscesses  are 
characterised  by  the  extensive  formation  of  pus  behind  the 
breast;  so  that  the  organ  appears  to  be  raised,  and  pushed 
forwards  by  an  elastic  cushion  behind  it.  The  local  and  con- 
stitutional symptoms  are  usually  less  severe  than  in  either  of 
the  foregoing  varieties,  and  the  progress  of  the  disease  is  by  no 
means  rapid.  Pus  generally  points  somewhere  at  the  periphery 
of  the  organ,  usually  in  the  infra-axillary  region.  This  is 
where  fluctuation  should  be  expected,  and  it  is  the  seat  of 
election  for  evacuating  the  pent-up  pus.  Abscesses  of  this 
kind  have  been  known  to  perforate  the  corpus  mammae,  and 
diffuse  themselves  over  the  surface  of  the  gland.  This  is  the 
form  of  the  disease  denominated  by  Velpeau  "  abces  de  buton  en 
cheviise." 

In  addition  to  pus  and  milk,  foetid  gas  has  occasionally  been 
noticed  to  escape  on  incising  these  abscesses.  Instead  of  their 
healing  up  after  evacuation,  it  not  unfrequently  happens  that 
a  discharging  fistula  results.  When  the  original  abscess  has 
been  in  free  communication  with  a  lacteal  duct,  the  resulting 
fistula  yields  chiefly  milk  ;  in  other  cases  only  puriform  fluid  is 
discharged.     These   fistulae    often    become   chronic,   and    prove 

^'  op.  cil.,  p.  82 


ACUTE    INFLAMMATION    AND    SUPPURATION.  55 1 

very  rebellious  to  treatment.  After  the  healing  of  mammary 
abscesses,  localised  chronic  induration  sometimes  remains,  which 
may  cause  the  patient  much  anxiety,  especially  when  associated 
with  tenderness  and  pain,  although  there  is  no  real  cause  for 
alarm. 

A  remarkable  feature  about  puerperal  abscesses  is,  that  in 
only  a  minority  of  cases  are  the  axillary  lymph  glands  not- 
ably affected,  and  even  under  these  circumstances  they  rarely 
suppurate. 

Of  the  complications  incidental  to  puerperal  inflammatory 
affections  of  the  breast,  the  most  grave  are  those  of  septic  origin, 
comprising  erysipelas,  septiccemia  and  pycsmia.  Fortunately,  these 
dread  diseases  are  of  rare  occurrence  in  this  connection,  and  there 
is  every  reason  to  believe  that  improved  methods  of  hygiene  and 
antiseptic  treatment  will,  in  the  future,  render  them  still  more 
exceptional.  In  the  severer  form  of  erysipelas  the  whole  organ 
may  be  very  rapidly  involved,  so  as  to  threaten  gangrene  unless 
timely  incisions  are  made. 

It  follows,  from  the  foregoing  account  of  the  pathogeny  of 
the  disease,  that  prophylactic  treatment  is  of  the  greatest  im- 
portance. This  comprises  attention  to  the  various  methods 
recommended  in  the  preceding  section,  for  obviating  the  ill- 
effects  of  mammillary  defects  and  inflammation.  On  the  super- 
vention of  lactation  great  care  should  be  taken  to  prevent 
engorgement  of  the  breasts  with  milk  by  regular  suckling  ;  or 
in  the  absence  of  this,  by  artificial  means — the  milk  being  drawn 
off  either  by  gentle  pressure  with  the  hands,  or  by  a  breast 
evacuator.  Attention  should  also  be  directed  to  the  child's 
mouth.  When  once  definite  symptoms  of  acute  inflammation 
have  set  in  it  is  generally  best  to  stop  suckling,  and  to  arrest 
the  secretion  of  milk.  Until  the  latter  object  has  been  effected 
suckling  must  be  replaced  by  mechanical  evacuation.  The 
nipple,  areola  and  adjacent  parts  should  be  purified  by  wash- 
ing with  carbolic  acid  lotion,  before  and  after  each  evacua- 
tion. To  arrest  the  lacteal  secretion  the  breast  should  be 
painted  with  extract  of  belladonna  in  glycerine.     To  allay  in- 


552  INFLAMMATION    AND    SUPPURATION. 

flammatory  irritation,  hot  boric  acid  fomentations  should  be 
apph'ed  over  this.  In  addition  the  part  should  be  adequately 
supported  ;  this  can  usually  be  done  most  efifectively  with  long, 
broad  strips  of  plaster,  properly  applied.  Another  necessary 
precaution  is  to  confine  the  upper  extremity  with  a  sling,  so 
as  to  prevent  its  movements  The  arrest  of  lacteal  secretion 
will  be  materially  aided  by  the  internal  administration  of  saline 
aperients,  together  with  iodide  of  potassium. 

When  once  pus  has  formed,  the  sooner  it  is  evacuated  the 
better.  The  requisite  incisions  should  be  made  in  lines  radiat- 
ing from  the  nipple,  so  as  to  avoid  cutting  across  the  lacteal 
ducts.  The  abscess  cavity  having  been  emptied,  and  if  neces- 
sary scraped,  it  should  be  purified  by  washing  out  with  carbolic 
acid  lotion.  Its  walls  should  then  be  coapted,  so  as  to  bring 
about  rapid  union  ;  and  to  render  this  efficient,  deep  embedded 
carbolised  catgut  sutures  should  be  used  if  necessary,  as  well  as 
superficial  cutaneous  ones.  In  small  abscesses  the  embedded 
sutures  are  usually  unnecessary,  if  well  adjusted  pressure  be 
applied  ;  and  in  such  cases  scraping  may  often  be  dispensed 
with.  Of  course,  to  secure  the  end  in  view,  antiseptic  precau- 
tions must  throughout  be  employed. 

Boeckel  recommends  that  the  entire  abscess,  together  with 
its  immediate  surroundings,  should  be  extirpated  by  cuneiform 
excision  ;  and  the  resulting  wound  closed  with  deep  and  super- 
ficial sutures,  so  as  to  secure  immediate  union.  This  method 
seems  to  me  better  adapted  for  the  treatment  of  certain  chronic 
fistulse,  than  for  acute  abscesses. 

As  soon  as  the  secretion  of  milk  has  been  arrested,  tonic 
treatment  and  regimen  should  be  adopted.  Ferri  et  quincs 
citras  is  one  of  the  most  suitable  tonics  for  this  purpose. 

The  treatment  of  fistula;  resulting  from  mammary  suppura- 
tion need  not  be  seriously  entertained,  until  the  lacteal  secretion 
has  been  arrested ;  when  after  a  time  they  often  heal  sponta- 
neously. The  method  hitherto  usually  adopted  for  their  cure, 
has  been  to  scrape  them  out  with  a  sharp  scoop,  at  the  same 
time  disinfecting  thoroughly  by  injection  of  solution  of  chloride 


ACUT?:    INFLAMMATION    AND    SUPPURATION.  553 

of  zinc  (gr.  20  to  40  ad.  i  oz.) ;  and  subsequently  by  compression 
and  the  use  of  gradually  shortened  drainage  tubes,  inducing 
them  to  heal  up  from  the  bottom.  This  method  is  now  being 
very  generally  superseded  by  excision  of  the  fistulous  tract,  or 
cuneiform  amputation,  with  immediate  closure  of  the  wound  by 
deep  and  superficial  sutures,  so  as  to  secure  rapid  healing.  For 
intractable  fistulae  these  proceedings  certainly  are  preferable  to 
Hey's  method  of  slitting  up  the  rebellious  sinuses  from  end  to 
end  ;  and  dressing  the  resulting  wounds,  so  that  they  may  heal 
up  from  the  bottom. 

(4)  It  is  only  very  exceptionally  that  inflammatory  afifec- 
tions  of  the  breasts  are  met  with,  other  than  at  some  of  the 
foregoing  periods.  Nevertheless,  cases  of  mastitis,  sometimes 
followed  by  suppuration,  do  occasionally  arise  in  both  sexes  at 
other  periods,  either  as  the  result  of  injury  or  without  any 
obvious  cause.  Probably  some  of  these  cases  are  of  rheumatic 
or  gouty  origin.  Inflammatory  affections  of  the  breasts  also 
sometimes  arise  during  malarial  and  other  fevers,  such  as 
typhoid ;  and  in  the  course  of  "  mumps."*^  From  abscesses 
thus  arising  chronic  fistulse  have  very  rarely  resulted  in  both 
sexes. 

Walther^''  has  lately  reported  the  case  of  a  man,  aged  40,  with  a  fistula  of 
his  right  breast,  of  three  years'  duration,  that  supervened  after  the  opening 
of  an  abscess. 


"*  For  a  case  by  Comby,  with  remarks,  vide  Le  Prog.  Med.,  18  fev.,  1893. 
^'  Bull,  de  la  Soc.  Anat.,  1890,  p.  300. 


554 


CHAPTER   XXIV. 
Tubercle,  Syphilis,  etc. 


§     I . Tubercle. 

The  history  of  mammary  tuberculosis  is  that  of  a  disease 
once  well  recognised,  which  after  a  time,  having  fallen  into 
oblivion,  has  in  comparatively  recent  times  been  re-discovered. 
Astley  Cooper,^  Nelaton,^  and  Velpeau^  long  ago  published 
excellent  descriptions  of  it. 

With  the  exception  of  histological  details,  Velpeau's  account 
has  never  been  surpassed.  He  recognised  that  the  breast  may 
be  primarily  affected,  which  is  rare;  or — the  initial  outbreak 
being  elsewhere — that  it  may  be  secondarily  involved,  as  more 
commonly  happens.  Its  various  manifestations  he  classed  as 
"  tubercles  dissemines"  "  tumeurs  lyinphatigiies,''  and  cold  abscess. 

(i)  In  the  disseminated  form,  numerous  nut-sized  nodules 
— apparently  formed  of  altered  lobules — are  met  with.  These 
are  often  tender,  and  even  slightly  painful.  Both  the  paren- 
chyma and  stroma  are  involved.  They  consist  of  caseous 
matter,  in  which  small  puriform  foci  are  often  noticeable.  He 
described  the  clinical  features  of  this  form  as  resembling,  in  its 
early  stage,  those  of  lobular  hypertrophy,  to  which  subsequently 
the   signs   of  chronic    mastitis    arc   added.     In    illustration    he 


'  "  Illust.  of  Diseases  of  the  Breast,"  1829,  cli.  viii. 

■^  "  These  d'Aggregation,"  Paris,  1839. 

^  "  Traite  des  Maladies  du  .Sein,"  &c.,  I'aris,  1854,  pp.  162  and  284. 


TUBERCLE.  555 

mentions  a  case  in  which  the  disease  lasted  four  years,  and  was 
accompanied  by  the  formation  of  an  enlarged  gland  in  the 
axilla.  The  patient  was  of  delicate,  lymphatic  constitution  ; 
but  not  obviously  affected  with  tubercular  disease  elsewhere. 

(2)  In  the  second  form  of  the  disease,  a  number  of  rather 
large  caseous  tumours  form  in  the  breast,  which  on  section  much 
resemble  enlarged  strumous  lymph  glands.  He  cites  two  cases 
of  this  kind  in  which  the  axillary,  cervical  and  other  lymph 
glands  were  involved  as  well  as  the  mammae.  In  a  rare  variety 
of  this  form,  "  tuineurs  lymphatiques purule7ites"  he  describes  the 
disease  as  presenting  as  a  single,  irregular,  bossed  tumour,  with 
concomitant  enlargement  of  the  axillary  glands.  After  a  time, 
which  may  be  long  or  short,  inflammatory  symptoms  supervene, 
which  result  in  suppuration.  From  the  loculated  abscess  cavity, 
grumous  caseous  matter  and  quasi-purulent  fluid  is  discharged. 
In  a  case  under  his  observation,  three  months  after  excision  of 
the  tumour,  fatal  pulmonary  tuberculosis  set  in,  and  after  death 
it  was  found  that  two  fresh  abscesses  had  formed  in  the  same 
breast.  He  considers  that  the  phthisical  are  the  most  liable  to 
this  form  of  the  disease ;  although  it  may  occur  as  a  primary 
affection.  Sometimes  abscesses  of  this  kind  in  the  mammary 
region  originate  from  disease  of  the  thoracic  skeleton  ;  or  even 
from  intra-thoracic  lesions. 

(3)  Cold  abscesses  of  the  breast  of  tubercular  origin  he 
describes  as  being  for  the  most  part  secondary  to  tubercular 
disease  elsewhere,  especially  in  the  lungs ;  but  he  also  recog- 
nises the  existence  of  a  primary  form  of  the  disease.  As  an 
example  of  the  latter  form  he  relates  the  following  case. 

A  woman,  over  40,  eighteen  months  previously  first  noticed  a  tumour 
in  her  breast,  which  she  thought  resulted  from  a  slight  blow.  It  rather 
quickly  increased,  but  without  any  pain  or  inflammatory  symptoms.  On 
examination  Velpeau  found,  at  the  upper  and  inner  part  of  her  right  breast, 
a  bossy  tumour — the  size  of  a  man's  fist — which  in  some  places  was  softish 
and  fluctuating,  and  in  others  as  hard  as  scirrhus.  On  incision  grumous 
material  and  puriform  fluid  escaped  ;  and  from  the  abscess  cavity  a  sinuous 
tract  passed  for  some  distance  in  the  direction  of  the  anterior  mediastinum, 
with  which,  however,  it  did  not  communicate.  The  adjacent  skeletal 
structures  were  normal  ;  and  there  was  no  sign  of  pulmonary  disease. 


55^  TUBERCLE,    SYPHILIS,    ETC. 

Subjoined  is  an  instance  of  tubercular  abscess  secondary  to 

phthisis, 

A  pale  and  emaciated  woman,  aged  24,  had  suffered  from  phthisical 
symptoms  for  about  six  months,  when  she  noticed  a  painful  swelling  in  her 
right  breast,  in  connection  with  which  several  nodules  were  subsequently 
noticeable.  When  she  was  first  seen  by  Velpeau  a  few  months  later,  the 
breast  was  occupied  by  a  mobile,  elastic  tumour,  the  size  of  an  apple.  It 
was  tender,  and  caused  some  pain.  The  overlying  skin  was  free,  and  the 
axillary  glands  were  normal  ;  but  the  nipple  was  depressed.  In  addition 
to  the  tumour,  there  was  general  lobular  hypertrophy  of  the  gland.  Soon 
afterwards  fluctuation  became  obvious,  the  swelling  was  incised,  and  the 
pus  evacuated.  A  fistulous  tract  persisted.  At  about  the  same  time  there 
were  marked  signs  of  actively  progressive  tubercle  in  the  upper  lobe  of  the 
right  lung.     Abscesses  of  this  kind  sometimes  contain  foetid  gas. 

With  this  lucid  account  available,  it  is  not  easy  to  under- 
stand how  subsequent  authors  could  possibly  have  overlooked 
the  disease.  Yet  so  it  came  to  pass,  English  pathologists  being 
particularly  deficient  in  this  respect. 

Although  in  his  well-known  work  on  "  Diseases  of  the 
Breast,"*  published  in  1880,  Billroth  gave  an  excellent  summary 
of  what  was  then  known  of  the  disease ;  yet  it  was  not  until 
the  appearance,  shortly  afterwards,  of  Dubar's  monograph,^  that 
mammary  tubercle  was  generally  recognised.  What  more 
than  anything  else  contributed  to  this  end  was  the  discovery 
by  Koch,^  in  1882,  of  the  tubercle  bacillus.  Since  the  announce- 
ment of  this  epoch-making  discovery,  the  subject  of  mammary 
tuberculosis  has  been  investigated  by  Ohnacher,^  Orthmann,^ 
Shattock,^  Mandry,^°  Roux,^^  and  many  others. 

It  is  now  generally  agreed  that  tubercle  of  the  breast  is  of 
much  commoner  occurrence  than  has  hitherto  been  generally 
believed.  In  primary  cases  it  seems  probable  that  infection 
usually   takes    place   through    the   milk    ducts,   although    the 

■*  Deutsche  Cliir.,  Lief,  xli.,  S.  30. 

^  "Des  Tubercles  de  la  Mamelle,"  Thise  de  Paris,  1881. 

•  "  Die  Aetiologie  der  Tuberkulose,"  Berl.  klin.  IVoch.,  No.  15,  1882. 
'  Arch.  f.  kliii.  Chir.,  1883,  Bd.  xxviii.,  S.  366. 

*  Arch.  f.  path.  Anat.,  Bd.  c,  Heft  3,  1885. 

°  Trans.  Path.  Soc.  Lond.,  vol.  xl.,  1889,  p.  391. 
'"  Beitrdge  z.  klin.  Chir.,  Bd.  viii.,  1891,  Heft  i. 
"  "  De  la  Tubcrculose  Mammaire,"  Paris,  1891. 


TUBERCLE.  557 

microbes  may  enter  from  infected  fissures,  &c.,  through  the 
lymphatics.  Most  cases  undoubtedly  arise  secondarily,  by  auto- 
infection  from  a  primary  focus  in  some  other  part  of  the  body, 
usually  the  lungs.^^  As  a  rule  the  disease  soon  disseminates 
in  the  adjacent  axillary  lymph  glands,  &c. 

In  the  breast,  as  elsewhere,  the  specific  effect  of  the  bacillus 
of  tubercle  is  to  produce  chronic  inflammatory  lesions.  These 
consist  largely  of  granulation  tissue,  which  must  be  regarded  as 
a  protective  provision  for  preventing  the  spread  of  the  microbes 
to  the  surrounding  healthy  tissues.  The  degenerative  changes 
that  subsequently  ensue  may  be  ascribed  to  local  anfemia,  and 
the  chemical  action  of  the  products  by  the  bacilli.  Thus  casea- 
tion and  liquefaction  of  the  cheesy  matter  into  a  fluid  resembling 
pus,  are  caused.  The  tubercle  bacillus  of  itself,  however,  pro- 
duces no  suppuration  ;  when,  therefore,  suppuration  supervenes, 
it  must  be  due  to  secondary  infection  from  pus  microbes. 
Spontaneous  cure  may  ensue  if  the  bacillus  meets  with  sufficient 
resistance  from  the  surrounding  phagocytes.  In  such  cases, 
the  nutriment  in  the  granulations  being  at  length  exhausted, 
the  bacilli  die  or  remain  latent  ;  and  cicatricial  tissue  replaces 
the  granulomatous  formation.  In  most  cases,  however,  abscesses 
and  chronic  fistulae  eventually  result. 

The  disease  debuts  in  connection  with  the  acini  and  small 
ducts.  After  a  time  their  lining  cells  disappear,  and  they 
are  replaced  by  giant  cells  surrounded  by  small  round  cells. 
Perfect  miliary  tubercles,  as  defined  by  Virchow,  are  not  usually 
met  with.  In  this  respect  the  disease  resembles  synovial  tuber- 
culosis and  lupus.  Moreover,  like  these  lesions,  mammary 
tubercle  is  of  a  comparatively  mild  form,  owing  to  its  poverty 
in  bacilli. 

As  previously  mentioned,  the  disease  usually  presents  as 
numerous,  rather  small,  pseud-inflammatory  nodules,  and  only 
exceptionally  as  single,  large,  tumour-like  swellings. 


'-  Of  26  cases  analysed  by  Delbet  (Duplay  and  Reclus,  Traite  de  Chir.,  t.  vi.,  p. 
208),  10  were  phthisical,  and  4  presented  tubercular  disease  elsewhere. 


558  TUBERCLE,    SYPHILIS,    ETC. 

Traumata  and  conditions  connected  with  the  puerperal  state 
favour  its  development.  Most  cases  arise  in  patients  from  25 
to  35  years  old,  after  40  it  is  rare,  and  after  50  most  exceptional. 
It  has  never  been  observed  under  puberty. 

The  onset  of  the  disease  is  usually  insidious,  and  its  pro- 
gress slow.  It  has  generally  existed  for  two  or  three  years 
before  abscess  formation  begins.  The  bacteriological  researches 
of  Schlegtendal,^^  Garre,^^  and  others  show  that  a  large  proportion 
of  cold  abscesses  are  of  tubercular  origin,  and  it  is  highly  prob- 
able that  this  conclusion  holds  also  for  the  breast.  It  is  in  the 
wall  of  these  abscesses  that  the  typical  tubercular  structures  are 
to  be  found,  including  the  bacilli.  After  incision  or  spontaneous 
evacuation,  should  infection  by  pus  microbes  take  place,  these 
are  apt  to  cause  destruction  of  the  protective  granulations  ;  which 
exposes  the  patient  to  the  risk  of  rapid  dissemination  of  the 
tubercular  disease,  as  well  as  to  the  risk  of  septic  infection. 
Hence  the  necessity  for  rigid  antiseptic  precautions  in  dealing 
with  such  cases.  Schlegtendal  claims  to  have  proved  that  the 
bacilli  in  tubercular  abscesses  do  not  grow  and  multiply. 

It  is  generally  believed  that  the  milk  from  tubercular  women 
does  not  possess  infective  properties,  unless  the  mammae  that 
supply  it  are  themselves  tubercular.^**  The  like  also  is  true  of 
cow's  milk,^*'  but  these  animals  are  more  prone  to  mammary 
tubercle  than  human  females. 

Niepce'^  has  instanced  a  case  in  which  a  nurse,  whose  milk  contained 
tubercle  bacilli,  suckled  a  child  born  of  healthy  parents,  with  the  result  that 
the  child  soon  afterwards  died  of  tubercular  meningitis. 

It  is  evident,  from  the  foregoing,  that  women  with  tubercular 
disease  of  the  breast  should  never,  under  any  circumstances,  be 
allowed  to  suckle  either  their  own  or  other  people's  children. 


'•'  Fortschritte  der  Med.,  Bd.  i.,  S.  537. 

"  Deutsche  vied.   Woch.,  No.  34,  1886. 

'■■  Fede,  Rif.  Med.,  Oct.  25,  1892. 

'"  Crookshank,  "  Tubercular  Mammitis  in  Cows  with  Kxperiments  relating  to  the 
Infectivity  of  the  Milk,"  Appendix  to  Rep.  Agriadt.  Dep.,  1888. 

"  "  De  la  contagion  et  de  la  transmissibilite  de  la  Tuberculose,"  TMse  de  Paris, 
1886 


TUBERCLE.  559 

Cases  seen  in  an  early  stage  of  the  disease,  when  the  diagnosis 
is  doubtful,  may  be  treated  by  local  application  of  belladonna 
and  glycerine  with  iodide  of  lead  ointment,  together  with  the 
internal  administration  of  syrup  of  iodide  of  iron,  and  cod-liver 
oil,  or  of  maltine  and  hypophosphites.  In  this  way  the  disease 
may  sometimes  be  cured.  When  the  disease  is  more  advanced 
and  suppuration  has  taken  place,  the  breast  must  usually  be 
extirpated,  together  with  the  affected  axillary  glands.  For 
localised  lesions  partial  amputation  may  suffice.  An  alterna- 
tive method  is  to  lay  open  and  scrape  the  abscess  cavity, 
sinuses,  &c.,  with  a  sharp  scoop,  at  the  same  time  syringing 
with  strong  solution  of  chloride  of  zinc,  and  afterwards  dressing 
from  the  bottom  with  glycerine  iodoform  emulsion.  Of  course 
antiseptic  dressings  and  precautions  must  be  employed. 

Instances  of  tubercle  of  the  male  breast  have  been  reported 
by  Mandry,^**  Horteloup,^^  and  Poirier,^^  but  in  men  the  disease 
is  exceedingly  rare. 

The  following  cases  illustrate  the  chief  features  of  mammary 
tuberculosis. 

(i)^'  A  rather  delicate-looking,  pale,  moderately  nourished  woman,  aged 
21,  six  years  ago  noticed  a  small  lump  in  her  left  breast,  which  was  followed 
one  year  ago  by  enlargement  of  the  axillary  glands.  There  had  occasionally 
been  slight  pain  in  connection  with  the  breast  tumour.  No  family  history 
of  tubercle.  On  examination  a  mobile  tumour,  rather  larger  than  a  hazel- 
nut, was  found  in  the  upper  and  outer  segment  of  the  left  breast.  The  over- 
lying skin,  when  pinched  up,  dimpled  slightly.  From  the  tumour  a  hard 
cord  extended  to  an  enlarged  gland  in  the  axilla.  No  fluctuation.  On  ex- 
ploratory excision,  a  thick-walled  abscess  containing  a  small  quantity  of 
thick  pus.  The  tumour  was  excised,  together  with  the  adjacent  part  of  the 
breast ;  and  several  caseous  axillary  glands,  the  largest  of  which  was  just  be- 
ginning to  soften.  A  thick  layer  of  granulation  tissue  lined  the  abscess  cavity. 
On  histological  examination  numerous  giant  cells  were  found  in  this  tissue,  but 
no  perfect  tubercle  systems.  Nothing  is  said  about  bacilli.  The  enlarged 
lymph  glands  presented  the  histological  characters  of  caseous  tubercle. 

(2)-^  A  woman,  aged  39,  the  mother  of  eight  children,  of  whom  five  had 

'*  Op.  cit. 

'"  "  Des  Tumeurs  du  Sein  chez  THomme,"  Paris,  1S72. 

™  Ibid.,  1883. 

-'  Shattock,  Trans.  Path.  Soc.  Load.,  vol.  xl. ,  1889,  p.  391. 

^^  Hebb,  Trails.  Path.  Soc.  Land.,   vol.  xxxvi.,  1SS8,  p.  446. 


560  TUBERCLE,    SYPHILIS,    ETC. 

died  of  tubercle.  She  had  suffered  from  phthisical  symptoms  for  many  years. 
About  seven  weeks  ago  she  experienced  pain  in  her  left  breast,  and  some 
weeks  later  a  tumour  was  noticed.  On  examination  a  hard  nodular  tumour, 
about  three-quarters  of  an  inch  in  diameter,  was  found  in  the  breast,  just 
above  and  external  to  the  nipple,  which  was  much  retracted.  It  was  freely 
movable,  rather  painful,  and  tender  on  manipulation.  There  were  a  few 
indurated  cords  stretching  towards  the  axilla  ;  but  the  axillary  lymph 
glands  were  not  obviously  affected.  The  tumour  was  excised  ;  and  when 
last  seen,  four  months  later,  the  patient  was  free  from  return  of  the  disease. 
On  examination  after  removal,  the  tumour  consisted  of  caseous  tubercular 
nodules,  some  of  which  were  softening  in  the  centre.  In  some  places  the 
tuberculosis  seemed  primarily  to  have  involved  the  ducts  ;  but  for  the  niost 
part,  the  nodules  were  embedded  in  the  stroma,  just  external  to  the  glandular 
structures.  They  contained  well-marked  giant  cells  ;  but  no  bacilli  could 
be  found  even  after  several  searches. 

(3)-^A  healthy-looking  spinster,  aged  38,  eighteen  months  ago  noticed  a 
small  sweUing  in  the  upper  part  of  her  left  breast.  It  gradually  increased 
in  size,  without  causing  any  pain.  Six  months  ago,  she  noticed  another 
swelling  at  the  inner  part  of  the  same  breast.  This  was  rather  painful,  and 
increased  more  rapidly  than  the  first  one.  No  history  of  injury  or  other 
known  cause.  A  maternal  aunt  died  of  cancer  of  the  breast.  There  was  no 
family  history  of  tubercle.  On  examination  two  swellings  were  found  in  the 
left  breast ;  the  one  in  its  upper  segment  was  large,  firm  and  non-fluctuating, 
the  other,  in  its  inner  segment,  was  soft  and  fluctuating.  Both  were  mobile 
and  devoid  of  inflammatory  symptoms.  There  was  slight  enlargement  of 
the  adjacent  axillary  glands.  On  free  incision,  the  swelling  in  the  inner 
part  of  the  breast  proved  to  be  a  puriform  collection  with  a  thick  granulo- 
matous wall.  On  squeezing  the  other  tumour,  caseous  matter  and  puriform 
fluid  escaped  into  the  abscess  cavity,  and  it  was  evident  that  the  two  com- 
municated. On  opening  the  upper  cavity  into  the  lower  one,  the  latter  was 
found  to  consist  of  seven  or  eight  cavities,  each  about  the  size  of  a  hazel-nut, 
containing  caseous  and  puriform  matter.  Antiseptic  irrigation  and  dressing, 
with  free  drainage.  No  bacilli  could  be  found  in  the  tissue  removed.  About 
two  months  later  she  again  came  under  treatment  with  a  discharging  sinus, 
and  the  axillary  glands  had  become  considerably  enlarged.  The  breast  was 
now  amputated  and  the  axilla  cleared.  Several  of  the  diseased  glands  were 
in  close  relationship  with  the  large  vessels.  On  section  after  removal 
numerous  small  caseous  nodules  were  found  scattered  throughout  its  upper 
part.  The  removed  axillary  glands  were  similarly  affected.  About  six 
weeks  later  the  wounds  had  quite  healed. 

The  integument  of  the   breast  is  occasionally  the  seat  of 

lupus,  which  may  affect  either  the  areolar  region  or  the   skin 

elsewhere.     Its  treatment  is  the  same  as  that  for  lupus  of  other 

parts  of  the  body — scraping  with  a  sharp  scoop,  igni-puncture, 

linear  scarification,  &c. 

■-'■■'  Lane,  Brit.  Med.  Journal,  Sept.  13,  1890. 


SYPHILIS.  5^^ 

§     II. Syphilis. 

Syphilis  of  the  breast  may  be  met  with  either  in  its  primary, 
secondary,  tertiary,  or  hereditary  forms. 

(i)  The  primary  form  usually  results  from  inoculation  of 
some  small  lesion  of  the  nipple  or  areola,  through  suckling  a 
syphilitic  child.  According  to  some  syphilographers,  a  mother 
may  thus  acquire  the  disease  from  her  own  child.  Those  usually 
affected  are  wet  nurses.  Both  breasts  are  often  affected,  and  the 
chancres  may  be  multiple.  In  dealing  with  cases  of  this  kind, 
as  Heath  tritely  remarks,  the  surgeon  should  keep  his  eyes  open 
and  his  mouth  shut.  After  the  usual  incubation  period,  a  hard 
chancre  forms  at  the  seat  of  inoculation  ;  subsequently  the 
axillary  glands  become  indurated,  and  secondary  symptoms 
develop.  The  disease  is  best  treated  by  the  local  application 
of  calomel  ointment,  and  by  mercury  internally  in  the  form  of 
pil.  hyd.  c.  opio,  or  some  other  suitable  preparation. 

(2)  Secondary  syphilis  of  the  breast  is  most  frequently  met 
with  in  the  form  of  erosions,  fissures,  papules,  tubercles,  or 
mucous  patches  of  the  nipple  or  areola.  In  women  with  large 
pendent  mammas,  lesions  of  this  kind  may  be  met  with  beneath 
the  overhanging  breasts,  where  the  two  cutaneous  surfaces  come 
into  contact.  These  secondary  manifestations  are  often  more  or 
less  bilateral,  and  they  are  usually  infectious.  They  are  often 
accompanied  by  evidence  of  specific  disease  of  other  parts  of  the 
body,  or  at  any  rate,  on  inquiry,  history  of  some  of  the  various 
manifestations  of  syphilis  can  generally  be  obtained.  In  select- 
ing a  wet  nurse  it  is  important  to  go  thoroughly  into  these 
matters,  for  the  syphilisation  of  a  healthy  child  by  its  nurse  is  a 
serious  affair.  It  is  believed  that  the  milk  of  a  syphilitic  woman 
cannot  communicate  the  disease,  in  the  absence  of  some  mam- 
mary lesion.  In  support  of  this  Lee^*  cites  the  following 
instructive  case : — 

A  healthy  married  woman,  shortly  after  her  last  confinement,  took  a  child 
to  nurse  in  addition  to  her  own.     The  strange  child  proved  to  be  syphilitic. 

*■•  Holmes'  "  System  of  Surgery,''  vol.  iii.,  1883,  p.  344. 
36 


562  TUBERCLE,    SYPHILIS,    ETC. 

Chancre  of  the  breast,  with  well-marked  secondaries,  followed  in  due  course. 
This  woman  had  taken  the  precaution  of  keeping  each  child  to  one  breast. 
Although  she  continued  to  suckle  her  own  child  for  six  weeks  after  the 
secondary  eruption  had  appeared,  yet  it  was  never  infected.  This  seems 
conclusive  evidence  that  in  the  absence  of  specific  disease  of  the  breast  itself, 
syphilis  cannot  be  communicated  through  the  milk. 

In  the  treatment  of  these  affections  the  same  routine  is 
generally  requisite  as  for  the  primary  disease. 

(3)  The  tertiary  syphilitic  manifestations  generally  present 
either  as  a  gumma,  or  as  a  diffuse  infiltration.  The  gummatous 
form  gives  rise  to  a  more  or  less  circumscribed  tumour,  which 
may  be  situated  in  any  part  of  the  breast.  It  is  usually  hard, 
bossed,  and  painless  in  its  early  stages ;  later  softening  sets  in, 
and  finally  it  breaks  down  into  an  excavated  ulcer.  In  its  early 
stages  the  overlying  skin  is  generally  free,  there  is  no  retraction 
of  the  nipple,  and  the  axillary  glands  are  seldom  affected.  In 
the  softening  stage  the  skin  becomes  adherent  and  discoloured, 
preparatory  to  breaking  down.  Evolving  mammary  gummata 
have  often  been  mistaken  for  cancer.  The  diagnosis  will  be 
simplified  by  the  discovery  of  signs  of  syphilis  in  other  parts  of 
the  body.  The  infiltrated  form,  in  its  general  features,  much 
resembles  chronic  mastitis,  before  contraction  sets  in.  There 
is  ill-defined,  painless  induration,  which  may  involve  the  whole 
gland,  or  only  certain  lobules.  The  overlying  skin  and  the 
nipple  are  unaffected,  and  the  axillary  glands  may  or  may  not 
be  enlarged.  Like  the  gummatous  form,  it  tends  to  softening 
and  ulceration.  These  affections  are  best  treated  with  iodide  of 
potassium  internally,  and  mercurial  ointment  with  belladonna 
externally. 

(4)  In  the  course  of  hereditary  syphilis  similar  lesions  may 
arise  in  the  breast.  As  I  have  previously  mentioned,  instances 
of  mammary  atrophy  consequent  on  hereditary  syphilis  have 
also  been  recorded.^^  For  further  information  on  the  subject 
of  mammary  syphilis,  the    reader  is  referred   to  the  works  of 


-^  P.  41. 


DIPHTHERIA.  563 

Fournier,^^   Jullicn,^''    Bumstead    and    Taylor/^    Claude/^    Lan- 
dreau^°   and    Lancereaux.^^ 

§    III . Diphtheria,  Thrush,  &c. 

The  following  instance  of  infection  of  the  mother's  breast 
with  diphtheria  by  her  suckling  child  has  been  recorded  by 
Caddy.32 

An  infant,  6  weeks  old,  that  had  hitherto  been  fed  exclusively  by  the 
breast,  was  found  to  be  very  ill,  temperature  103°  F.,  with  acute  inflamma- 
tion of  the  tonsils,  the  left  being  covered  with  a  large  patch  of  white  mem- 
brane, which  extended  to  the  adjacent  parts  of  the  uvula  and  soft  palate. 
The  submaxillary  glands  were  somewhat  enlarged.  The  mother  was 
advised  at  once  to  cease  suckling  ;  but  this  she  declined  to  do,  fearing  that 
the  child  would  die  if  she  did.  Five  days  later,  the  mother  complained  of 
feeling  weak  and  ill,  and  of  having  cold  shivers,  as  well  as  of  tenderness  in 
her  left  breast  and  axilla.  On  examination,  the  breast  was  swollen,  hard, 
tense  and  very  tender  ;  the  nipple  was  covered  with  a  tough,  greyish-white 
membrane,  which,  on  the  axillary  side,  extended  to  the  outer  border  of  the 
areola.  There  were  several  other  small  patches  of  membrane  in  this 
vicinity.  After  removal  of  the  membrane  a  raw  bleeding  surface  was  ex- 
posed. For  the  distance  of  about  an  inch  around  the  areola,  the  breast  was 
red  and  inflamed.  Temperature  103-2°  F.  The  urine  contained  a  good 
trace  of  albumen.  Under  appropriate  treatment  both  mother  and  child 
recovered. 

In  like  manner  thrush  may  be  transferred  from  the  child's 
mouth  to  the  mother's  nipple,  although  this  is  a  comparatively 
rare  occurrence. 

Mention  has  previously  been  made  of  the  occasional  infec- 
tion of  the  mammary  integument  with  niolhtscuin  contagiosum 
derived  from  the  child's  face. 


^*"De   la    Syphilis   chez   la    Femme ; "     "La   Syphilis   Hereditaire  Tardive" 
(1886)  ;  "L'Heredite  Syphilitique  "  (1891). 
'-'  "  Maladies  Veneriennes  •"'  (1886). 
-°  "  Treatise  on  Venereal  Diseases." 
-»  Thlse  de  Paris,  1886. 
^  Ibid.,  1874. 

5'  "  Traile  de  la  Syphilis,"  1866. 
^-  Brit.  Med.  Jour.,  vol.  i.,  1893. 


564 


CHAPTER    XXV. 

Traumata,  Neuroses,  Minor  Surgery. 


§    I. Traumata. 

The  commonest  form  of  mammary  trauma  is  contusion.  The 
ecchymosis  consequent  on  blows  of  no  great  violence,  as  a  rule, 
soon  passes  away,  and  is  followed  by  no  bad  results.  Severer 
forms  of  injury  give  rise  to  extensive  ecchymosis  or  even  to 
haematoma.  In  this  connection  it  is  well  to  recollect  that  simi- 
lar lesions  may  arise  in  young  women,  as  a  form  of  vicarious 
menstruation,  or  from  other  causes,  in  the  absence  of  any 
traumatism.  In  like  manner  spontaneous  haemorrhage  from  the 
nipple  may  occur.  Haimorrhagic  extravasations,  after  a  time, 
are  generally  absorbed,  but  sometimes  chronic  induration 
remains,  or  a  cyst  may  form.  It  not  unfrequently  happens 
after  contusions,  that  pain  is  felt  for  a  long  time,  even  when 
there  is  no  appreciable  lesion.  Sometimes  blows  excite  inflam- 
mation, especially  in  the  puerperal  state,  when  it  may  easily 
pass  on  to  suppuration.  Belladonna  with  mercury  ointment  is 
a  good  application  for  most  contusions ;  and  when  it  can  be 
borne,  the  breast  should  be  strapped  with  emplast.  am.  c.  hyd. 

With  regard  to  zvoiuids  of  the  breast,  they  differ  but  little 
from  those  met  with  in  other  parts  of  the  body.  Stabbed  and 
bullet  wounds  are  the  most  serious,  and  they  are  relatively 
of  frequent  occurrence.  Haemorrhage  can  nearly  always  be 
arrested  by  judicious  compression.  In  their  treatment  anti- 
septic measures  should  occupy  the  first  place  ;  foreign  bodies 
must  be  removed  ;  and  the  wound  surfaces  be  brought  together 
by  carefully  applied  dressings,  &c. 

Various  foreign  bodies^  such  as  needles,  pins  and  bits  of 
glass,  have  often  been  found  embedded  in  the  breast.     Burns 


NEUROSES.  565 

and  scalds^  which  are  rare,  differ  in  no  way  from  similar  lesions 
elsewhere. 

8     II. Neuroses. 

Young  adult  women  not  uncommonly  experience  tenderness 
in  the  mammae  at  the  catamenial  periods  and  at  the  commence- 
ment of  pregnancy.  Somewhat  similar  sensations  are  apt  to 
arise  at  the  climacteric,  and  in  association  with  various  morbid 
conditions  of  the  pelvic  organs.  Exaggeration  of  this  sensitive- 
ness leads  to  mastodynia.  In  this  affection  the  degree  of  pain 
experienced  is  very  variable.  Sometimes  it  is  so  severe  that 
the  slightest  touch  cannot  be  endured.  It  may  be  constant  or 
only  occasional.  In  some  cases  it  is  localised  to  a  particular 
spot ;  in  others  it  is  widely  diffused,  radiating  to  the  shoulder, 
arm  and  side.  In  most  cases  there  is  no  obvious  mammary 
lesion  ;  but  it  occasionally  happens  that  mastodynia  is  asso- 
ciated with  the  presence  of  a  small  tumour  or  chronic  inflam- 
matory induration. 

Those  affected  are  generally  of  hysterical  or  neurotic  dis- 
position. In  this  state  patients  sometimes  consult  us,  firmly 
convinced  that  they  have  cancer,  or  some  other  grave  disease 
of  the  breast  requiring  operation.  These  require  to  be  reassured. 
Local  sedatives  should  be  applied,  such  as  belladonna  plaster. 
For  general  treatment  pil  quincB  valerianatis,  or  mist,  ferri  et 
qiiincs  citratis  will  suffice.  In  erotic  individuals  bromide  of 
potassium,  with  saline  aperients,  are  indicated.  Purely  hysterical 
cases  are  best  managed  on  the  Weir  Mitchell  principle,  in- 
cluding complete  change  of  surroundings.  Should  catamenial 
irregularities  or  diseases  of  the  pelvic  organs  co-exist,  these 
must  be  appropriately  treated.  When  mastodynia  is  associated 
with  chronic  induration  or  tumour,  compression  is  often  curative, 
and  in  many  other  cases  it  may  be  beneficially  employed. 

§     III . Minor  Surgery. 

One  of  the  most  convenient  ways  of  keeping  in  place  fomen- 
tations and  other  applications  to  the  breast  is  by  means  of  the 


566  TRAUMATA,     NEUROSES,    MINOR    SURGERY. 

triangular  bandage,  which  is  made  from  a  square  yard  of  calico, 
cut  or  folded  diagonally.  It  may  be  applied  in  either  of  the 
following  ways:  —  (i)  In  the  first  method  the  base  of  the 
triangle  is  passed  from  over  the  opposite  shoulder,  beneath  the 
affected  breast,  to  the  back,  where  the  two  ends  are  fastened 
with  safety  pins.  The  rectangular  end  is  then  carried  over  the 
shoulder  of  the  affected  side  to  the  back,  where  it  is  also 
secured.  (2)  In  the  second  method  the  base  of  the  triangle 
is  passed  round  the  waist  beneath  the  mammae,  the  ends  being 
fastened  behind  ;  the  rectangular  end  is  then  passed  over  the 
shoulder  of  the  affected  side  to  be  fastened  to  the  basal  part 
behind.  In  fixing  the  ends  of  the  bandage  behind,  whichever 
method  is  used,  care  should  be  taken  to  avoid  having  the 
junctions  over  the  middle  line,  as  otherwise  they  will  cause  the 
patient  much  annoyance  when  reclining. 


Fig.  75. — Wicker's  breast  supporter. 

A  form  of  made  bandage  known  as  "Wicker's  breast  sup- 
porter" is  simple  and  efficient  (fig.  75).^ 

Chadbourne's^  arrangement  is  also  a  good  one  :  the  breast  is 
embraced  between  the  Y-shaped  extremities  of  a  transverse 
bandage  approaching  it  from  opposite  sides. 

When  a  certain  amount  of  compression  is  required  together 
with  support,  the  roller  bandage  is  often  employed,  although  it 
is  a  comparatively  inefficient  application.  To  bandage  one 
breast — let  us  say  the  rigJit — a  roller  3  inches  wide  and  8  yards 
long  is  taken.  It  is  first  carried  round  the  waist,  immediately 
below  the  mammae,  beginning  in  front  and  passing  towards  the 


'  Supplied  by  Arnold  &  Sons,  West  Sniithfield,  London. 

*  Made  by  Madels,  Codman  and  Shurtleff,  Boston,  U.S.A.;    as  described  in  Am, 
Obstet.  Jour.,  Nov.,  1890,  p.  I2CXJ. 


MINOR    SURGERY.  567 

left  side.  The  bandage  being  thus  fixed,  is  carried  obliquely 
upwards  over  the  lower  part  of  the  right  breast  to  the  opposite 
shoulder,  then  back  by  the  axilla  to  the  waist,  around  which  it 
passes  so  as  to  fix  the  oblique  turn.  By  repetition  of  the  above 
turns,  each  being  a  little  higher  than  its  predecessor,  the  breast 
is  covered  in.  In  order  to  bandage  both  mammae  the  initial 
part  of  the  process  is  the  same  as  for  only  one.  The  roller 
having  been  carried  over  the  lower  part  of  the  right  breast  to 
the  opposite  shoulder  and  back  to  the  waist  by  the  axilla,  is 
then  carried  half  round  the  waist  and  across  the  back  to  the 
right  shoulder  over  which  it  passes,  and  then  across  the  sternum 
under  the  left  breast,  and  round  the  back  to  the  right  side. 
By  repetition  of  these  turns  both  breasts  are  covered  in.  The 
objections  to  bandages  are,  that  they  are  tedious  to  apply,  that 
they  soon  slip,  and  that  they  are  apt  to  prove  irksome  by 
impeding  the  respiratory  movements. 

Another  mode  of  bandaging,  sometimes  useful  in  the  treat- 
ment of  mammary  diseases,  is  the  anterior  figure  of  eight,  trans- 
versely applied.  Starting  behind  one  shoulder,  over  which  the 
roller  is  passed,  it  is  carried  downwards  and  forwards  across  the 
front  of  the  sternum  to  the  opposite  axilla  ;  beneath  which  it 
is  carried  up  and  over  the  same  shoulder,  thence  downwards 
and  forwards  over  the  front  of  the  chest  to  the  first  axilla, 
crossing  the  other  turn  in  the  middle  line.  By  repeating  this, 
so  that  the  succeeding  turns  overlap  to  the  requisite  extent,  the 
bandage  is  completed. 

For  supporting  and  compressing  the  breast  strapping  \z  much 
more  effective  and  less  incommodious  than  bandaging,  and  it 
should  therefore  generally  be  preferred  when  support  is  the  chief 
object.  Strips  of  plaster  from  two  to  three  inches  wide  and 
about  thirty  inches  long  are  taken.  The  breast  being  held  up 
by  an  assistant,  the  end  of  the  strip  is  fixed  to  the  back  over  the 
scapula,  it  is  then  brought  forwards  across  the  axilla,  whence  it 
is  passed  upwards  and  outwards  beneath  the  lower  part  of  the 
diseased  breast,  over  the  opposite  shoulder,  where  it  is  fixed  to 
the  back,  over  the  upper  part  of  the  scapula.     A  few  other  strips, 


568 


TRAUMATA,  NEUROSES,  MINOR  SURGERY. 


similarly  applied,  so  that  each  may  overlap  its  predecessor,  com- 
pletes the  application. 

When  compression  is  the  end  in  view  transverse  and  oblique 
strips  are  laid  on  alternately  as  in  bandaging.  The  strips  should 
not  be  more  than  two  inches  wide,  and  the  transverse  ones  only 
embrace  the  affected  side. 


Fig.  76. — Duke's  breast  supporter  and  compressor. 

For  the  exercise  of  long  continued  compression,  in  cases  of 
chronic  tumour  of  doubtful  nature,  &c ,  the  most  efficient  instru- 
ment known  to  me  is  Arnott's.''  It  is  essentially  a  modified 
Salmon  and  Ody's  truss,  adapted  to  the  breast.  The  compress- 
ing pad  is  fitted  with  a  slack  air  cushion.  It  has  the  great 
advantage  of  not  interfering  with  the  respiratory  movements. 

Where  support  with  moderate  compression  is  required  Duke's 
instrumenf*  is  advisable.  By  means  of  a  spiral,  cone-shaped 
spring,  so  arranged  as  not  to  interfere  with  respiration,  both 
support  and  compression  are  effected. 


'  Made  by  Coxeter  and  Son,  Grafton  Street,  Gower  Street,  London,  W.C. 
*  Made  by  Arnold  and  Sons,  West  Smithfield,  London,  E.G. 


INDEX 


Abdominal  mammte,  46,  59,  60,  71. 

Abscess  and  defective  nipples,  38,  297, 
338,  542  ;  microbes,  525,  555  ;  cold, 
539,  555  ;  acute,  546  ;  tubercular,  555. 

Acini,  20. 

Acromial  mammce,  49. 

Adenoma,  vide  fibro-adenoma. 

Agalactia,  13. 

Amazia,  29. 

Anatomy,  16. 

Angioma,  489,  512. 

Anomalies  of  secretion,  15. 

Areola — Morphology,  16,  23  ;  develop- 
ment, 5  ;  defective,  29,  et  seq.  ;  eczema, 
393>  545  ;  cancer,  393,  413  ;  sore,  542  ; 
tumours,  461,  493,  506,  514. 

Atavistic  polymastia,  44,  53. 

Athelia,  37. 

Atrophy,  39. 

Axilla  —  Anatomy,  25  ;  anatomico- 
pathological  memorabilia,  345  ;  can- 
cer of  axillary  glands,  179;  galacto- 
celes,  (>^  ;  lymphatics  and  lymph 
glands,  185 ;  lumps  of  Champneys,  3, 
25,  517;  mammary  processes,  dT,; 
mammary  sequestrations,  67;  mam- 
mary neoplasms,  74  ;  nipples,  &c.,  72  ; 
neoplasms  and  tumours,  516;  recur- 
rence of  cancer  in,  217 ;  supernu- 
merary mammary  structures,  63  ;  sweat 
glands,  25. 

Bandaging,  566. 
Birth,  mammee  at,  6. 

Calcification,  22,  169,  228,  434. 

Cancer,  132-416. — Acinous,  123,  151; 
acute,  318;  age,  233,  284;  alcohol, 
290 ;  alimentation,  250,  289  ;  alveoli, 
169;  amyloid  degeneration,  214;  ana- 
tomico-pathological memorabilia,  345; 
animals,  299;  antecedent  inflammation, 
297;  anxiety  and  mental  distress,  292; 
apoplexy,  273 ;  arrest  and  retrogres- 
sion, 229  ;   arthroses,  274  ;   associated 


Cancer — {continued). 

with  sarcoma,  304  ;  with  other  neo- 
plasms, 309,  384 ;  with  hyperplasia, 
172  ;  asthenia  as  mode  of  death,  216  ; 
atrophic,  325 ;  auto-inoculation,  148, 
223,350;  axillary,  77;  axillary  glands, 
183;  axillary  recurrence,  217.  Biologi- 
cal distribution,  298  ;  blastema  theory, 
135  ;  blood  changes,  212;  blood  supply 
and  rate  of  growth,  193,  224 ;  blood 
vessels,  170;  both  breasts,  153,  176, 
194,  204,  301,  318;  Broussaisian 
theory,  134,  141,  295.  Cachexia,  210; 
calcifying,  167,  169,  228 ;  capsular 
lipomatosis,  228 ;  cartilage  in  the 
stroma,  170  ;  caseating,  228  ;  caustic 
treatment,  268  ;  cell  theory,  134  ;  cell 
nuclei,  159;  cell  vacuolation,  166; 
cell  secretion,  167  ;  centenarians  little 
liable,  241  ;  chemical  analysis,  171  ; 
chloroma,  333  ;  chronic  inflammation, 
&c.,  141,  295;  chronic  types,  323; 
clinical  features,  152 ;  coagulable  lymph 
theory,  133;  coccidial  theory,  163; 
Cohnheim's  theory,  73,  137 ;  colloid, 
328  ;  complexion,  247  ;  congestion, 
171,  224;  contagion,  145,  147;  con- 
tinuous development  theory,  136  ;  con- 
troversy as  to  origin,  137  ;  constitution, 
272,  2S5  ;  cuirassed,  321  ;  cure — opera- 
tive, 363  ;  spontaneous,  229,  233  ;  cu- 
taneous, 393  ;  cylindroma,  331  ;  cysts, 
22S.  Deaths  consequent  on  operation, 
360  ;  death  independently  of  opera- 
tion, 216  ;  definition,  151  ;  depraved 
lymph  theory,  133  ;  dermatoses,  292  ; 
diathesis,  475  ;  diet,  250,  289 ;  differ- 
ential diagnosis,  339;  diffuse,  318; 
dimpling  of  skin,  338  ;  discharge  from 
nipple,  339;  dissemination,  local,  174; 
glands,  179;  general,  191  ;  seats  of, 
195  ;  bones,  197  ;  fractures  due  to,  203, 
327  ;  traumatic,  223  ;  rationale,  207  ; 
domestication,  299;  duct  cancer,  384; 
duration  of  life,  153,  365.    Encephaloid, 


570 


INDEX. 


CSinceT^conh'meed). 

an  obsolete  term,  152;  endocytes,  162, 
397  ;  enlarged  lymph  glands,  179  ; 
epidemiology,  147;  epitheliome  tubule, 
392 ;  erysipelas  after  operation,  362. 
Family  history,  264 ;  fatty  degenera- 
tion, &c.,  166,  214,  225,  227;  fe- 
cundity, 275,  288 ;  fractures  due  to 
dissemination,  203,  327 ;  due  to  ca- 
chexia, 215  ;  frequency,  as  compared 
with  other  neoplasms,  131.  (Gallstones, 
294 ;  gangrene,  225 ;  general  mor- 
phology, 151;  general  pathology,  233; 
geographical  distribution,  249  ;  germs, 
139;  gi^ief,  292.  Hpemorrhage,  227; 
hemorrhagic  cancer,  228 ;  healing, 
229  ;  health,  285,  292  ;  heredity,  260  ; 
hereditary  proclivities,  270  ;  historical 
review,  132 ;  homologous  and  hetero- 
logous, 135  ;  hyperplasia  concomitant 
with  cancer,  172  ;  humoral  theory,  132. 
Immunity  of  savages  and  wild  animals, 
248,  291,  299;  inclusions  in  cells,  162; 
increase,  279  ;  infection,  147  ;  inflam- 
mation of,  224  ;  inoculation,  145  ;  in- 
sanity, 273  ;  integumentary,  393  ;  irri- 
tation, &c.,  140,  295.  Karyokinesis, 
160.  Lactation,  288  ;  leucocytes,  165, 
169  ;  liability  to  other  diseases,  293  ; 
lipomatous,  227  ;  local  dissemination, 
174;  localisation,  234;  locality,  in- 
fluence of,  151  ;  longevity  in  cancer 
families,  274;  lymphatics  of  the  breast, 
185  ;  lymphatics  and  cancer,  167, 
171  ;  lymph  glands  of  breast,  184  ; 
lymph  gland  enlargement,  179;  lymph 
gland  dissemination,  180 ;  lympho- 
cytes, 169.  Male  breast,  333,  403  ; 
malignancy,  174;  marriage,  287; 
mastitis,  297  ;  melanotic,  331,  413  ; 
membrana  propria,  114,  167;  men- 
struation, 244,  287 ;  metastases,  191  ; 
microbes,  specific,  137,  143,  163,  171, 
397;  non-specific,  164,  350;  mitoses 
of  cancer  cells,  160;  morphology,  151  ; 
mortality  after  operation,  360;  multiple 
primary  cancers,  300  ;  myxomatodes, 
331.  Nerves,  171 ;  nipple  cancer,  393, 
413;  nipple  discharges,  339;  nipple 
retraction,  297,  337,  542  ;  nitric  acid 
method  of  examination,  173  ;  non- 
malignant  neoplasms  and  cancer,  310  ; 
nuclei  of  cancer  cells,  161  ;  nutrition 
in  relation  to  pathogeny,  245  ;  nu- 
trition of  cancerous  growths,  223  ; 
nutrition  of  cancer  patients,  285. 
Occupation,  292  ;  oedema  of  upper 
limb,  185;  operative  treatment,  344, 
352  ;  origin  of  cancer,  157,  246,  310, 
481;  ossifying,  170;  osteitis  defor- 
mans, 291.  Paget's  disease,  393,  413; 
pain,  336;  palliative  treatment,   370; 


Ca.ia.cev—{ion/zmted). 

parasitism,  138,  140,  163,  397  ;  patho- 
genesis, 122,  132,  246;  pathology,  233; 
peripheral  neuritis,  213  ;  phagocytosis, 
165  ;  prevalence,  279  ;  prevalence 
greater  in  rural  districts  and  among 
the  well-to-do,  290 ;  previous  health, 
293  ;  primary  neoplasm,  156  ;  prisons, 
290  ;  proclivity,  157  ;  prolongation  of 
life  by  operation,  365  ;  prostitution, 
291.  Race,  248  ;  recurrence,  217  ; 
retraction  of  nipple,  337  ;  retrogres- 
sion, 229 ;  roots,  156  ;  rural  districts, 

290.  Savages,  248,  291,  299  ;  scirrhus, 
156;  septic  diseases  after  operation, 
362;  sex,  233;  spontaneous  cure,  229; 
spontaneous  fracture,  203,  215,  327  ; 
steriHty,  287  ;  stroma,  168  ;  suppura- 
tion,  224  ;   symptoms,   336  ;   syphilis, 

291.  Tetanus,  362  ;  topography,  253  ; 
traumata,  295  ;  traumatic  dissemina- 
tion, 149  ;  trees,  300  ;  treatment — 
operative,  344 ;  caustic,  368  ;  pallia- 
tive, 370  ;  tubercle,  270,  285,  286, 
294;  tubular  cancer,  123,  151,  384, 
413.  Ulceration,  225.  Vacuolation  of 
cancer  cells,  166  ;  varieties — acinous, 
I57i  403;  acute,  318;  chronic,  223; 
colloid,  328 ;  atrophic,  325  ;  myxo- 
matodes, 331  ;  tubular,  384,  413  ; 
villous,  372  ;  cutaneous,  393,  412. 

Cartilage  in  stroma,  &c.,  22,  169,  434, 
444,  451,  486,  512. 

Castration,  effect  on  mammae,  41. 

Chloroma,  333. 

Chondroma,  486,  512. 

Climacteric  mammary  changes,  13 

Cohnheim's  theory,  73,  137. 

Compressors,  568. 

Cooper's  ligaments,  16,  174,  347. 

Corpus  mammoe,  18. 

Cylindroma,  331. 

Cysts— axillary,  68,  517  ;  dermoids, 
507,  514,  522  ;  galactoceles,  68,  494, 
574  ;  general  cystic  disease,  497,  514  ; 
hydatids,  504 ;  involution  cysts,  13, 
501  ;  lymphatic,  503  ;  lymphangioma, 
522 ;  mucoid,  493,  514  ;  sebaceous, 
506,  514,  517. 

Descent  of  mammals.  2 

Development  —  asymmetrical,  11; 
defective,  29 ;  excessive,  43,  82  ;  of 
mamma,  5>  81;  of  nipple,  9;  of  neo- 
plasms, 119,  130. 

Diathesis,  neoplastic,  475.* 

Diphtheria,  563. 

Dorsal  mammiv,  47. 

Ducts,  20,  113. 

Eczema,  393,  545. 
Erratic  mamma;,  47. 


INDEX. 


571 


Facial  mammre,  48. 
Fibroma,  458,  509. 

Fibro -adenoma,  460,  510;   axillary, 

74  ;  cancer  after  removal  of,  482  ; 
chronic  mammary  tumour,  460  ;  con- 
comitant lobular  hypertrophy  and 
hyperplasia,  465  ;  cystic  theory  of  ori- 
gin, 465  ;  diagnosis,  477  ;  diffuse,  478  ; 
in  early  life,  471  ;  family  history  and 
heredity,  475  ;  general  pathology, 
471  ;  history  of  discovery,  461  ;  mi- 
crobe theory  of  origin,  479 ;  milk 
secreting  adenoma,  462  ;  morpho- 
logy, 464  ;  neoplastic  diathesis,  475  ; 
origin  of  malignant  disease  from,  310  ; 
pathogenesis,  123,462,464;  plexiform 
fibroma,  478,  535  ;  recurrence,  480 ; 
treatment,  479 ;  true  adenoma,  462  ; 
Thomas'  operation,  480. 

Foreign  bodies  in,  506. 

Frequency  of  various  neoplasms,  127. 

Galactocele,  494  ;  axillary,  67 ;  in 
male,  514. 

Galactophorous  ducts,  20,  113. 

Galactorrhoea,  14. 

Glandulje  lactiferse  aberrantes  (Mont- 
gomery's glands),  10,  25. 

Groin,  mamma  in,  50. 

Gynecomastia,  104. 

Hermaphroditism,  3,  30,  35,  37,  no. 

Herpes  zoster,  546. 

Heterochronous  lactation,  15. 

Histology,  23,  113. 

Homologue  of  mamma,  4. 

Hypertrophy,  82;  adults,  91;  com- 
pensatory, 98  ;  diffuse,  85  ;  etiology, 
97  ;  fatty,  88,  94  ;  fibrous,  85  ;  glandu- 
lar, 92  ;  gynecomastia,  104  ;  infantile, 
83  ;  male  animals,  106  ;  morphology, 
85 ;  partial,  loi  ;  pregnancy,  92  ;  pro- 
gress, 95 ;  puberty,  85  ;  treatment, 
ICO,  103,  112, 

Infantile  lactation,  6,  83. 
Inflammation  and  suppuration,  525. 
Inguinal  mamma,  50. 
Injury  in  newly  born,  33. 
Innervation,  I19. 
Involution,  13,  39,  501. 

Kenogenesis  in  nipple  development,  4. 

Labium  majus,  mamma  in,  51. 

Lactation,  12;  adenoma,  462;  ano- 
malies, 13;  cancer,  288;  girls,  15; 
histology,  115  ;  infantile,  6,  82;  man 
and  male  animals,  16,  105  ;  non-preg- 
nant women  and  virgins,  15. 

Ligamenta  suspensoria  of  Cooper,  16, 
174,  347- 


Linece  atrophica;,  13. 

Lipoma,  126,483,  511. 

Localisation  of  neoplasms,  127,  185. 

Lymphatics,  114. 

Lymphatic  glands,  183. 

Male  breast.  Angioma,  512,  315; 
cancer,  333,  403  ;  chronic  mastitis, 
534i  539  ;  cold  abscess,  541  ;  chon- 
droma, 512  ;  cysts,  513  ;  fibroma, 
509  ;  fibro-adenoma,  510  ;  fistula,  553  ; 
galactocele,  514;  gynecomastia,  105  ; 
lactation,  3,  103  ;  lipoma,  511  ; 
melanoma,  333,  413  ;  myxoma,  457  ; 
osteoma,  512  ;  sarcoma,  456  ;  subacute 
mastitis  concomitant  with  pulmonary 
tubercle,  535  ;  tubercle,  559 ;  villous 
papilloma,  510. 

Mammse  erraticte,  47 ;  mammce  in  various 
animals,  43  ;  multiple,  45. 

Mammary  ridges  of  Schultze,  81. 

Man,  antiquity  and  descent,  2. 

Mastitis,  525  ;  acute,  546  ;  associated 
with  phthisis,  533  ;  chronic,  529  ;  cold 
abscess,  539  ;  with  inflammation,  &c., 
of  the  nipple,  542 ;  with  malformed 
nipple,  548;  in  male,  534,  539,  541, 
535.  559 ;  niicrobes,  525. 

Median  nipples,  &c. ,  52. 

Membrana  propria,  114. 

Micromazia,  33. 

Moles,  491. 

Molluscum  contagiosum,  563  ;  fibrosum, 
460. 

Montgomery's  gland,  10,  25  ;  tubercles, 
12,  24. 

Morphology,  11. 

Myoma,  491. 

Myxoma,  125,  450,  457. 

Neoplasms,  73,  119,  127. 

Neoplastic  diathesis,  475. 

Neuroma,  491. 

Neuroses,  563. 

Nerve  supply,  119. 

Nipple,  absence,  37  ;  anatomy,  23 ; 
cancer,  393,  413  ;  defective,  38,  297, 
338,  542,  548;  discharges,  339; 
eczema,  545,  393  ;  histology,  23 ; 
kenogenesis,  4 ;  imperforate,  38  ;  in- 
flammation, 542  ;  muscles  of,  21  ; 
ontogeny,  8  ;  papilloma,  374,  491  ; 
phylogeny,  8 ;  relation  to  subjacent 
ribs,  17;  retraction,  297,  337,  542. 

Ontogeny,  3,  8. 
Origin  of  mamme,  I,  8. 
Osteoma,  486,  512. 

Ovarian  dermoids,  containing  mammary 
structures,  54. 


:)/ 


INDEX. 


Papilloma,    cutaneous,    491  ;     villous, 

373,  510 

Paramammary  neoplasms,  73. 

Phylogeny  of  breast,  I  ;  and  nipple,  8. 

Polymastia,  43  ;  animals,  60  ;  asso- 
ciated with  other  anomalies,  62 ; 
axillary,  63,  72  ;  diagnosis,  63  ; 
diverse  races,  60  ;  erratic,  47  ;  general 
pathology  of,  55 ;  heredity,  56,  62 ; 
origin  of  neoplasms  from,  73  ;  phylo- 
genetical,  43  ;  polythelia,  56  ;  rever- 
sion, 53  ;  sex,  55  ;  sports,  53  ;  twining, 
61. 

Post-embryonic  variations,  11. 

Pregnancy,  mammary  signs  of,  11. 

Processes,  axillary,  64  ;  cutaneous,  19. 

Puberty,  the  mammae  at,  7. 

Retarded  development,  11. 

Sarcoma,  417;  adeno-sarcoma,  426; 
age,  442  ;  alveolar,  448  ;  analysis  of 
thirty  cases,  419  ;  axillary  glands, 
438  ;  clinical  features,  443  ;  cysts  and 
intra-cystic  growths,  430,  434 ;  dis- 
semination, 439 ;  duration  of  life, 
441  ;  fungus  hsematodes,  437  ;  genesis, 
124,  418,  428;  heredity,  421,  425, 
442 ;  male,  456 ;  malignancy,  438  ; 
microbes,  433;  m\x(  ma,  450,  457; 
non-cystic,  429  ;  pure  sarcoma,  444 ; 
recurrence,  439 ;  relative  frequency, 
417  ;   rhabdo-myo-sarcoma,  433  ;   sex. 


Sarcoma — (continued). 

417  ;  statistical  summary  of  cases,  419, 
424  ;  stroma,  433 ;  treatment,  443. 

Scabies,  546. 

Secretion,  mammary,  115. 

Secretory  anomalies,  13. 

Secondary  sexual  characters,  2. 

Segmental  organs,  the  mammie  as,  45. 

Shape,  tricuspid,  19- 

Shoulder,  mamma  on,  49. 

Sinus  lacteus,  21. 

Size  of  mammre,  17. 

Sports,  53. 

Strapping,  567. 

Stroma,  22,  114. 

Sweat  glands  of  axilla,  25, 

Syphilis,  41,  561. 

Supernumerary  mammary  structures,  43. 

Thelothism,  22. 

Thigh,  redundant  mamma  on,  49,  50. 

Thrush,  563. 

Traumata,  564. 

Tubercle,  554. 

Variations,  post-embryonic,  11. 
Varieties   of    mammary   neoplasms    and 

their  relative  frequency,  127. 
Virgins,  lactation  in,  15. 
Vulvar  mamina,  51. 

Weaning,  as  cause  of  atrophy,  40. 
Weight  of  mammoe,  17,  40. 


c-  V. 


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